Provider Demographics
NPI:1528515046
Name:RILEY, NICOLAS
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:RILEY
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 1:5301 BAINBRIDGE AVE
Mailing Address - Street 2:BOX #52
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-9041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD.
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5007
Practice Address - Country:US
Practice Address - Phone:228-822-5409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman