Provider Demographics
NPI:1942074547
Name:KWONG, RILEY JAMISON
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:JAMISON
Last Name:KWONG
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 1:300 HARVEY WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2103
Mailing Address - Country:US
Mailing Address - Phone:831-425-8132
Mailing Address - Fax:
Practice Address - Street 1:300 HARVEY WEST BLVD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2103
Practice Address - Country:US
Practice Address - Phone:831-425-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No172V00000XOther Service ProvidersCommunity Health Worker