Provider Demographics
NPI:1336685726
Name:RUSH, RILEY (ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:RILEY
Middle Name:
Last Name:RUSH
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S HARKRIDER ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-8066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 E 14TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6915
Practice Address - Country:US
Practice Address - Phone:580-559-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000025671OtherBOARD OF CERTIFICATION (BOC)
AR904OtherARKANSAS STATE BOARD OF ATHLETIC TRAINING
OK948OtherOKLAHOMA MEDICAL BOARD