Healthcare Provider Details

I. General information

NPI: 1790411379
Provider Name (Legal Business Name): DANIEL SIXTO RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 04/07/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY STE 106
SAN DIEGO CA
92102-4544
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY STE 106
SAN DIEGO CA
92102-4544
US

V. Phone/Fax

Practice location:
  • Phone: 619-772-2579
  • Fax: 619-717-8863
Mailing address:
  • Phone: 619-772-2579
  • Fax: 619-717-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: