Provider Demographics
NPI:1508563495
Name:RILEY, BRADLEY H
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:H
Last Name:RILEY
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:PO BOX 8054
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43702-8054
Mailing Address - Country:US
Mailing Address - Phone:740-624-1036
Mailing Address - Fax:
Practice Address - Street 1:61205 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-8002
Practice Address - Country:US
Practice Address - Phone:740-439-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician