Provider Demographics
NPI:1659417178
Name:RELLER, RICHARD GLEN (OTRL)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GLEN
Last Name:RELLER
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13327 N 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-9119
Mailing Address - Country:US
Mailing Address - Phone:602-769-2532
Mailing Address - Fax:
Practice Address - Street 1:13327 N 152ND AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-9119
Practice Address - Country:US
Practice Address - Phone:602-769-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ102478174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist