Provider Demographics
NPI:1689308991
Name:LISS, RILEY
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:LISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-3147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:827 E LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-3504
Practice Address - Country:US
Practice Address - Phone:817-275-0655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10682T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist