MEDICARE: LUIS J RIVAS CADC III

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11-12-94	OR

General Provider Information

NPI Number	:	1710347356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS J RIVAS CADC III

Provider Business Mailing Address
First Line	:	10920 SW BARBUR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97219-8600
Country	:	US
Telephone Number	:	503-244-4500
Fax Number	:	503-244-2008

Provider Business Practice Location Address
First Line	:	10920 SW BARBUR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97219-8600
Country	:	US
Telephone Number	:	503-244-4500
Fax Number	:	503-244-2008

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

Provider Enumeration Date	:	02/24/2016
Last Update Date	:	02/24/2016

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