Healthcare Provider Details

I. General information

NPI: 1811704125
Provider Name (Legal Business Name): ANDERW Q RIOVEROS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 FENTON ST STE A
CHULA VISTA CA
91914-3517
US

IV. Provider business mailing address

311 BROADWAY
CHULA VISTA CA
91910-3501
US

V. Phone/Fax

Practice location:
  • Phone: 619-591-7000
  • Fax: 619-591-7049
Mailing address:
  • Phone: 619-422-0404
  • Fax: 619-422-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT307190
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT307190
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT307190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: