Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 4191 | OK |
NPI | 1003040551 |
---|---|
Provider Name | Irving Riley |
First Address | Midwest City, OK 73110-1760 |
Second Address | Midwest City, OK 73110-1760 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2009 |
Last Update Date | 13/05/2009 |