Provider Demographics
NPI:1497870703
Name:RILEY, KEVIN PAUL (LMT, NCTMB)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PAUL
Last Name:RILEY
Suffix:
Gender:M
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2138
Mailing Address - Country:US
Mailing Address - Phone:207-356-2895
Mailing Address - Fax:
Practice Address - Street 1:147 PALM ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4021
Practice Address - Country:US
Practice Address - Phone:207-356-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3184225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist