MEDICARE: RILEY SELF

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1447883640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RILEY SELF

Provider Business Mailing Address
First Line	:	3226 N CLARK ST APT 6D
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1602
Country	:	US
Telephone Number	:	615-809-6393
Fax Number	:

Provider Business Practice Location Address
First Line	:	3226 N CLARK ST APT 6D
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1602
Country	:	US
Telephone Number	:	615-809-6393
Fax Number	:

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

Provider Enumeration Date	:	02/16/2020
Last Update Date	:	02/16/2020

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Directions to “ RILEY SELF ” Practice Location

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