Provider Demographics
NPI:1467086314
Name:LANG, RILEY QUINN
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:QUINN
Last Name:LANG
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 1:1322 LOGANS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1322 LOGANS LAKE RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2785
Practice Address - Country:US
Practice Address - Phone:660-888-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-01
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program