Provider Demographics
NPI:1962084897
Name:RILEY, LOGAN LAYNE
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:LAYNE
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 1:103 STONE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-1465
Mailing Address - Country:US
Mailing Address - Phone:803-457-0077
Mailing Address - Fax:
Practice Address - Street 1:200 UNIVERSITY RDG
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3635
Practice Address - Country:US
Practice Address - Phone:803-457-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic