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General NPI Number Information
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NPI Number | 1346507209
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Entity Type | Organization
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Legal Business Name | JOANNA LYNN RILEY
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Dates
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Enumeration Date | 04/17/2012
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Last Update Date | 09/14/2012
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Provider Practice Location Address
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Address Line | 2760 N GRANDVIEW AVE SUITE A
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City | ODESSA
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State | TX
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Zip | 79762-6953
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Country | US
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Telephone | 432-552-7034
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Fax | 432-552-7165
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Provider Business Mailing Address
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Address Line | PO BOX 14774
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City | ODESSA
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State | TX
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Zip | 79768-4774
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Country | US
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Telephone | 432-638-4544
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Fax | 432-362-1449
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Authorized Official
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Title or Position | OWNER
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Name | MS. JOANNA RILEY
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Credential | LOT
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Telephone | 432-638-4544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 109122
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License Number State | TX
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