Provider Demographics
NPI:1881863892
Name:RILEY, JOHN CHARLES (LMT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHARLES
Last Name:RILEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:187 E CRYSTAL LAKE AVE
Mailing Address - Street 2:SUITE 2005
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3207
Mailing Address - Country:US
Mailing Address - Phone:407-496-0990
Mailing Address - Fax:407-688-1891
Practice Address - Street 1:187 E CRYSTAL LAKE AVE
Practice Address - Street 2:SUITE 2005
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3207
Practice Address - Country:US
Practice Address - Phone:407-496-0990
Practice Address - Fax:407-688-1891
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-23
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist