Provider Demographics
NPI:1902447204
Name:CROFTON, REILLY
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:CROFTON
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 1:210 W HUGHES ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61031-9450
Mailing Address - Country:US
Mailing Address - Phone:815-677-1090
Mailing Address - Fax:
Practice Address - Street 1:210 W HUGHES ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN GROVE
Practice Address - State:IL
Practice Address - Zip Code:61031-9450
Practice Address - Country:US
Practice Address - Phone:815-677-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant