Healthcare Provider Details

I. General information

NPI: 1851117493
Provider Name (Legal Business Name): MARISA RILEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 JEFFERSON ST STE 104
AUSTIN TX
78731-6204
US

IV. Provider business mailing address

PO BOX 290
TABERNASH CO
80478-0191
US

V. Phone/Fax

Practice location:
  • Phone: 303-720-4134
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: