Provider Demographics
NPI:1447921432
Name:CLYDE, RILEY WILLIS (DPT)
Entity type:Individual
Prefix:DR
First Name:RILEY
Middle Name:WILLIS
Last Name:CLYDE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-0013
Mailing Address - Country:US
Mailing Address - Phone:435-654-0410
Mailing Address - Fax:435-654-0440
Practice Address - Street 1:190 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1600
Practice Address - Country:US
Practice Address - Phone:435-654-0410
Practice Address - Fax:435-654-0440
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12243556-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist