Healthcare Provider Details

I. General information

NPI: 1912303595
Provider Name (Legal Business Name): ELLI M RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

IV. Provider business mailing address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

V. Phone/Fax

Practice location:
  • Phone: 415-507-2000
  • Fax: 415-507-4381
Mailing address:
  • Phone: 415-507-2000
  • Fax: 415-507-4381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: