Provider Information for 1063959468
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TARA RILEY
Sex: Female
NPI: 1063959468
Last Updated: 2017-01-23
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1063959468 | ||||||||
| Enumeration Date | 2017-01-23 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 109 TRENT ST BOYNE CITY, MI 49712-1542 United States Phone: 231-330-2895 | Fax: | ||||||||
| Primary Practice Address | 616 PETOSKEY ST 005 PETOSKEY, MI 49770-2985 United States Phone: 231-330-2895 | Fax: | ||||||||
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