Provider Demographics
NPI:1679031348
Name:FAKE, RILEY (DC)
Entity Type:Individual
Prefix:DR
First Name:RILEY
Middle Name:
Last Name:FAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:1914 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-2535
Practice Address - Country:US
Practice Address - Phone:617-323-4377
Practice Address - Fax:617-323-8077
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3651111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor