Basic Information
Provider Information | |||||||||
NPI: | 1164500021 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIEDL | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | KENNETH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | PHD.,M- R.A.S., MCA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RIEDL | ||||||||
OtherFirstName: | KEN | ||||||||
OtherMiddleName: | KEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | II | ||||||||
OtherCredential: | PHD.,M- R.A.S., MCA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2055 SAVIERS RD | ||||||||
Address2: |   | ||||||||
City: | OXNARD | ||||||||
State: | CA | ||||||||
PostalCode: | 930333608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054832253 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2055 SAVIERS RD | ||||||||
Address2: |   | ||||||||
City: | OXNARD | ||||||||
State: | CA | ||||||||
PostalCode: | 930333608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054832253 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 09/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 103211032 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 103211032 | 01 | CA | REGITERED ADDICTION SPEC | OTHER |