Provider Demographics
NPI:1235781501
Name:WILSON, RILEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5184 WATERFRONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROWNS VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56219
Mailing Address - Country:US
Mailing Address - Phone:320-808-7024
Mailing Address - Fax:
Practice Address - Street 1:415 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2614
Practice Address - Country:US
Practice Address - Phone:605-886-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty