Healthcare Provider Details

I. General information

NPI: 1942679386
Provider Name (Legal Business Name): EDWARD RILEY P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
OCEANSIDE CA
92058
US

IV. Provider business mailing address

627 PASEO RIO
VISTA CA
92081-6322
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-4357
  • Fax:
Mailing address:
  • Phone: 760-936-3969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number29590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: