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NPI Code Detail

MEDICARE: HOLBROOK RILES JR. O.D.

MEDICARE: HOLBROOK RILES JR. O.D.
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
1152W00000XOptometrist3710/P1203OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1780686873
Entity Type Code : Individual
Provider Name (Legal Business Name) : HOLBROOK RILES JR. O.D.
Provider Business Mailing Address
First Line : 949 STATE ROUTE #314 SOUTH
Second Line :
City : MANSFIELD
State : OH
Zip : 44903-7797
Country : US
Telephone Number : 419-756-7295
Fax Number : 419-756-7574
Provider Business Practice Location Address
First Line : 2485 POSSUM RUN RD
Second Line :
City : MANSFIELD
State : OH
Zip : 44903-9447
Country : US
Telephone Number : 419-756-7295
Fax Number : 419-756-7574
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/02/2005
Last Update Date : 03/03/2014

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