Provider Demographics
NPI:1548987456
Name:RILEY, LUCY KATHLEEN (ATC)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:KATHLEEN
Last Name:RILEY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:KATHLEEN
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9309 LA MESA DR APT B
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5834
Mailing Address - Country:US
Mailing Address - Phone:626-409-9015
Mailing Address - Fax:
Practice Address - Street 1:9535 ARCHIBALD AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5737
Practice Address - Country:US
Practice Address - Phone:909-941-6167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer