Healthcare Provider Details

I. General information

NPI: 1003937194
Provider Name (Legal Business Name): JOSE ANTONIO RIVERA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 ATLANTIC AVE STE D
CUDAHY CA
90201
US

IV. Provider business mailing address

3434 N. ROBINETTE AVE
BALDWIN PARK CA
91706
US

V. Phone/Fax

Practice location:
  • Phone: 323-562-3414
  • Fax: 323-562-3100
Mailing address:
  • Phone: 323-562-3414
  • Fax: 323-562-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: