Healthcare Provider Details

I. General information

NPI: 1013489236
Provider Name (Legal Business Name): RILEY C LYVERS MS, ATC, NASM-CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 05/07/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 3RD AVE. APT 15
HUNTINGTON WV
25701-6849
US

IV. Provider business mailing address

13776 MCCABE DR
ORLAND PARK IL
60467-6849
US

V. Phone/Fax

Practice location:
  • Phone: 708-267-4465
  • Fax:
Mailing address:
  • Phone: 708-267-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001778
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: