Provider Demographics
NPI:1649901026
Name:BLANKENHORN, RILEY
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:BLANKENHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 SATORI WAY
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2744
Mailing Address - Country:US
Mailing Address - Phone:952-258-3560
Mailing Address - Fax:
Practice Address - Street 1:533 SATORI WAY
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2744
Practice Address - Country:US
Practice Address - Phone:952-258-3560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0423001Medicaid