Provider Demographics
NPI:1093235855
Name:RILEY, RETTA LYNN
Entity Type:Individual
Prefix:
First Name:RETTA
Middle Name:LYNN
Last Name:RILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 ORTIZ DR SE # 100
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5592
Mailing Address - Country:US
Mailing Address - Phone:505-463-1970
Mailing Address - Fax:
Practice Address - Street 1:1258 ORTIZ DR SE # 100
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5592
Practice Address - Country:US
Practice Address - Phone:505-463-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72129859Medicaid