MEDICARE: MR. DAVID EDWARD RIOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS18811	CA

General Provider Information

NPI Number	:	1417087370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID EDWARD RIOS

Provider Business Mailing Address
First Line	:	80 HIGHLAND AVE
Second Line	:
City	:	SAN MARTIN
State	:	CA
Zip	:	95046-9504
Country	:	US
Telephone Number	:	408-683-4053
Fax Number	:	408-683-0697

Provider Business Practice Location Address
First Line	:	80 HIGHLAND AVE
Second Line	:
City	:	SAN MARTIN
State	:	CA
Zip	:	95046-9504
Country	:	US
Telephone Number	:	408-683-4053
Fax Number	:	408-683-0697

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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