=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013489236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RILEY C LYVERS MS, ATC, NASM-CES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2018
-----------------------------------------------------
Last Update Date | 05/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1408 3RD AVE. APT 15
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25701-6849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-267-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13776 MCCABE DR
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-6849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-267-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT001778
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------