Basic Information
| Provider Information | |||||||||
| NPI: | 1073110557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STILES | ||||||||
| FirstName: | RYLEIGH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STILES | ||||||||
| OtherFirstName: | RYLEIGH | ||||||||
| OtherMiddleName: | NIKOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RBT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6201 COLLEYVILLE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760346236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179528917 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6201 COLLEYVILLE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLLEYVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760346236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179528917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-138284 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-20138284 | 01 | TX | RBT | OTHER |