MEDICARE: RILEY C LYVERS MS, ATC, NASM-CES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		IL
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2255A2300X	Athletic Trainer	AT001778	WV

General Provider Information

NPI Number	:	1013489236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RILEY C LYVERS MS, ATC, NASM-CES

Provider Business Mailing Address
First Line	:	13776 MCCABE DR
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60467-6849
Country	:	US
Telephone Number	:	708-267-4465
Fax Number	:

Provider Business Practice Location Address
First Line	:	1408 3RD AVE. APT 15
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-6849
Country	:	US
Telephone Number	:	708-267-4465
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2018
Last Update Date	:	05/07/2023

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