Provider Demographics
NPI:1619560265
Name:ALLEN, RILEY WALTZ
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:WALTZ
Last Name:ALLEN
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 1:339757 E 890 RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-7066
Mailing Address - Country:US
Mailing Address - Phone:405-318-6644
Mailing Address - Fax:
Practice Address - Street 1:339757 E 890 RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-7066
Practice Address - Country:US
Practice Address - Phone:405-318-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist