Provider Demographics
NPI:1912368119
Name:RIEGLE, KEVIN RICHARD WAYNE (ATC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD WAYNE
Last Name:RIEGLE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7397 W TOPEKA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5608
Mailing Address - Country:US
Mailing Address - Phone:602-618-5443
Mailing Address - Fax:
Practice Address - Street 1:18424 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1443
Practice Address - Country:US
Practice Address - Phone:602-618-5443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0517246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other