MEDICARE: MARIAH RIOS-GONZALEZ

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	246RP1900X	Phlebotomy Technician	29732-165-124-5443	WI

General Provider Information

NPI Number	:	1750026217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAH RIOS-GONZALEZ

Provider Business Mailing Address
First Line	:	1433 N WATER ST STE 400
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-2603
Country	:	US
Telephone Number	:	414-732-1857
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 N WATER ST STE 400
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-2603
Country	:	US
Telephone Number	:	414-732-1857
Fax Number	:

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

Provider Enumeration Date	:	04/29/2022
Last Update Date	:	04/29/2022

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