Healthcare Provider Details

I. General information

NPI: 1699618777
Provider Name (Legal Business Name): RAVEN RIORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 LEES SUMMIT RD
KANSAS CITY MO
64139-1236
US

IV. Provider business mailing address

4615 DOVER HILLS DR APT 206
KALAMAZOO MI
49009-1466
US

V. Phone/Fax

Practice location:
  • Phone: 816-404-7000
  • Fax:
Mailing address:
  • Phone: 314-605-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: