Provider Demographics
NPI:1962618041
Name:RILEY, LAQUITA (PT)
Entity type:Individual
Prefix:
First Name:LAQUITA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 N SEDGWICK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67204-1831
Mailing Address - Country:US
Mailing Address - Phone:316-821-9550
Mailing Address - Fax:
Practice Address - Street 1:5701 N SEDGWICK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67204-1831
Practice Address - Country:US
Practice Address - Phone:316-821-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11-2599Medicare UPIN