Healthcare Provider Details

I. General information

NPI: 1124621495
Provider Name (Legal Business Name): BRANDON RILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E BUSINESS WAY SUITE 200
CINCINNATI OH
45241-2384
US

IV. Provider business mailing address

6269 SAVANNAH AVE
CINCINNATI OH
45224-1913
US

V. Phone/Fax

Practice location:
  • Phone: 303-989-8169
  • Fax:
Mailing address:
  • Phone: 513-348-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: