Provider Demographics
NPI:1487862736
Name:RILEY, JOHN WESLEY (LMT, MTI)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WESLEY
Last Name:RILEY
Suffix:
Gender:M
Credentials:LMT, MTI
Other - Prefix:MR
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, MTI
Mailing Address - Street 1:4407 BEE CAVE RD
Mailing Address - Street 2:SUITE 513
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6405
Mailing Address - Country:US
Mailing Address - Phone:512-732-0037
Mailing Address - Fax:512-328-3228
Practice Address - Street 1:4407 BEE CAVE RD
Practice Address - Street 2:SUITE 513
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6405
Practice Address - Country:US
Practice Address - Phone:512-732-0037
Practice Address - Fax:512-328-3228
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT003331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist