Provider Demographics
NPI:1992917108
Name:JEFFREY D RIES D O A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JEFFREY D RIES D O A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:RIES
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:909-579-0779
Mailing Address - Street 1:1310 SAN BERNARDINO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4979
Mailing Address - Country:US
Mailing Address - Phone:909-579-0779
Mailing Address - Fax:909-579-0789
Practice Address - Street 1:1310 SAN BERNARDINO RD
Practice Address - Street 2:STE 101
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4985
Practice Address - Country:US
Practice Address - Phone:909-579-0779
Practice Address - Fax:909-579-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX51380Medicaid
CAF15239Medicare UPIN
CA00AX51380Medicaid