=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922733716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RILEY FLOYD LPTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2022
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5847 GETWELL RD STE A5
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-6816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-349-2489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5847 GETWELL RD STE A5
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-6816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 225200000X
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------