Healthcare Provider Details

I. General information

NPI: 1205490620
Provider Name (Legal Business Name): JERRY RIVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date: 07/12/2023
Reactivation Date: 08/04/2023

III. Provider practice location address

205 39TH ST
RICHMOND CA
94805-2212
US

IV. Provider business mailing address

3655 MIDVALE AVE APT 4
OAKLAND CA
94602-3863
US

V. Phone/Fax

Practice location:
  • Phone: 510-412-5930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: