Provider Demographics
NPI:1912546938
Name:RILEY, ETTA MARIE (CEO/OWNER)
Entity Type:Individual
Prefix:MS
First Name:ETTA
Middle Name:MARIE
Last Name:RILEY
Suffix:
Gender:F
Credentials:CEO/OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1934
Mailing Address - Country:US
Mailing Address - Phone:612-522-3370
Mailing Address - Fax:
Practice Address - Street 1:3622 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1934
Practice Address - Country:US
Practice Address - Phone:612-522-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNM933160273015343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)