Provider Demographics
NPI:1013664796
Name:RILEY, SHANNON (VICE PRESIDENT OF OP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:VICE PRESIDENT OF OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 MEMORIAL CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5063
Mailing Address - Country:US
Mailing Address - Phone:386-951-5571
Mailing Address - Fax:386-287-5776
Practice Address - Street 1:570 MEMORIAL CIR STE 110
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5063
Practice Address - Country:US
Practice Address - Phone:386-951-5571
Practice Address - Fax:386-287-5776
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2251415OtherCLIA