Provider Demographics
NPI:1821426909
Name:RILEY, CEDRIC
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:RILEY
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 1:974 HALE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-6305
Mailing Address - Country:US
Mailing Address - Phone:901-650-5390
Mailing Address - Fax:
Practice Address - Street 1:974 HALE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6305
Practice Address - Country:US
Practice Address - Phone:901-650-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver