Healthcare Provider Details

I. General information

NPI: 1780606228
Provider Name (Legal Business Name): JEFFREY B. RILEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LAIDLEY ST
CHARLESTON WV
25301-1614
US

IV. Provider business mailing address

331 LAIDLEY ST SUITE 606
CHARLESTON WV
25301-1619
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-0096
  • Fax: 304-342-4725
Mailing address:
  • Phone: 304-344-0096
  • Fax: 304-342-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number040914
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: