Healthcare Provider Details

I. General information

NPI: 1740175959
Provider Name (Legal Business Name): MR. JUSTIN DAVID RILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 CALIFORNIA AVE STE 100
BAKERSFIELD CA
93309-0794
US

IV. Provider business mailing address

3817 AMUR MAPLE DR
BAKERSFIELD CA
93311-2624
US

V. Phone/Fax

Practice location:
  • Phone: 661-634-9877
  • Fax:
Mailing address:
  • Phone: 661-437-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1609380425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: