Provider Demographics
NPI:1144749789
Name:QUAN, RILEY
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:QUAN
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 1:21726 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-7116
Mailing Address - Country:US
Mailing Address - Phone:626-848-4344
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE RM 58
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist