Provider Demographics
NPI:1700206422
Name:RILEY, TAYLOR W (DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:W
Last Name:RILEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 SEVEN SPRINGS WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4576
Mailing Address - Country:US
Mailing Address - Phone:815-381-7431
Mailing Address - Fax:815-381-7498
Practice Address - Street 1:1073 W LANE RD
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-1622
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13225225100000X
IL070-020806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILF400165711Medicare PIN