Provider Demographics
NPI:1558825166
Name:RILEY, CODY (PTA)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:RILEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10133 SHERRILL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-3347
Mailing Address - Country:US
Mailing Address - Phone:901-281-8170
Mailing Address - Fax:
Practice Address - Street 1:118 GLASS ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4625
Practice Address - Country:US
Practice Address - Phone:731-424-2951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6568225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant