Provider Demographics
NPI:1891738126
Name:RILEY, CRAIG BRADLEY
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:BRADLEY
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 1:1320 S MINNESOTA AVE
Mailing Address - Street 2:#104 PROACTIVE PHYSICAL THERAPY
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-332-2565
Mailing Address - Fax:605-332-2506
Practice Address - Street 1:1320 S MINNESOTA AVE
Practice Address - Street 2:#104 PROACTIVE PHYSICAL THERAPY
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-332-2565
Practice Address - Fax:605-332-2506
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5832080Medicaid
SD6212Medicare ID - Type Unspecified