Provider Demographics
NPI:1700984135
Name:RILEY, LAURIE JO (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:JO
Last Name:RILEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E BELL RD
Mailing Address - Street 2:SUITE 152
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9306
Mailing Address - Country:US
Mailing Address - Phone:602-992-9791
Mailing Address - Fax:602-258-9664
Practice Address - Street 1:4550 E BELL RD
Practice Address - Street 2:SUITE 152
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9306
Practice Address - Country:US
Practice Address - Phone:602-992-9791
Practice Address - Fax:602-258-9664
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5878111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ80198Medicare ID - Type Unspecified
AZU92308Medicare UPIN