Healthcare Provider Details

I. General information

NPI: 1124503776
Provider Name (Legal Business Name): RANDAL ANTHONY RILEY JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3319 S 68TH ST
MILWAUKEE WI
53219-4030
US

IV. Provider business mailing address

3319 S 68TH ST
MILWAUKEE WI
53219-4030
US

V. Phone/Fax

Practice location:
  • Phone: 414-412-5088
  • Fax:
Mailing address:
  • Phone: 414-412-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number321568
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number252849-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: