Provider Demographics
NPI:1093590838
Name:MOORE, RILEY DALE
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:DALE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 E INDIAN SCHOOL RD APT 249
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5496
Mailing Address - Country:US
Mailing Address - Phone:641-590-6259
Mailing Address - Fax:
Practice Address - Street 1:19555 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6813
Practice Address - Country:US
Practice Address - Phone:623-572-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program