1215361324 NPI number — KELLEY RIEGNER M.A., A.T.C., O.T.C.

Table of content: KELLEY RIEGNER M.A., A.T.C., O.T.C. (NPI 1215361324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215361324 NPI number — KELLEY RIEGNER M.A., A.T.C., O.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIEGNER
Provider First Name:
KELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., A.T.C., O.T.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215361324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1330 S FINLEY RD
Provider Second Line Business Mailing Address:
APT 3L
Provider Business Mailing Address City Name:
LOMBARD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60148-4322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-573-2909
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
WESTMONT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60559-6135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
690-794-8668
Provider Business Practice Location Address Fax Number:
630-920-2382
Provider Enumeration Date:
08/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  096.003798 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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