Provider Demographics
NPI:1497464853
Name:RIOS, PHILLIP JR (RADT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:RIOS
Suffix:JR
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82435 REQUA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-4108
Mailing Address - Country:US
Mailing Address - Phone:760-609-6135
Mailing Address - Fax:
Practice Address - Street 1:44199 MONROE ST STE B
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3094
Practice Address - Country:US
Practice Address - Phone:760-863-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1454361221101YA0400X, 324500000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty