Provider Demographics
NPI:1255949822
Name:MOHR, RILEY
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:MOHR
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 1:5511 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-4377
Mailing Address - Country:US
Mailing Address - Phone:707-328-0752
Mailing Address - Fax:
Practice Address - Street 1:5511 RAINBOW CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-4377
Practice Address - Country:US
Practice Address - Phone:707-328-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16612044Medicaid