Provider Demographics
NPI:1720729783
Name:RILEY, CHARLES H (CNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:RILEY
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18602 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2231
Mailing Address - Country:US
Mailing Address - Phone:734-639-9791
Mailing Address - Fax:
Practice Address - Street 1:18602 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2231
Practice Address - Country:US
Practice Address - Phone:734-639-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI00001864376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide