Provider Demographics
NPI:1124216973
Name:MONTY S. RILEY, O.D., P.C.
Entity Type:Organization
Organization Name:MONTY S. RILEY, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:423-875-3060
Mailing Address - Street 1:3217 ALTA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4102
Mailing Address - Country:US
Mailing Address - Phone:423-875-3060
Mailing Address - Fax:
Practice Address - Street 1:314 NORTHGATE MALL
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-6922
Practice Address - Country:US
Practice Address - Phone:423-875-3060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT1416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU37886Medicare UPIN
TN3598681Medicare PIN