Provider Demographics
NPI:1932856192
Name:RIORDAN, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RIORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6831
Mailing Address - Country:US
Mailing Address - Phone:678-855-2930
Mailing Address - Fax:
Practice Address - Street 1:2901 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-2811
Practice Address - Country:US
Practice Address - Phone:970-243-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0001554224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant