Healthcare Provider Details

I. General information

NPI: 1922565613
Provider Name (Legal Business Name): VIRGINIA RIVAS REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA RIVAS

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6723 N 61ST AVE
GLENDALE AZ
85301-3108
US

IV. Provider business mailing address

PO BOX 16906
PHOENIX AZ
85011-6906
US

V. Phone/Fax

Practice location:
  • Phone: 623-206-4841
  • Fax: 602-279-1431
Mailing address:
  • Phone: 602-279-1427
  • Fax: 602-279-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9262536
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: