Healthcare Provider Details

I. General information

NPI: 1265360002
Provider Name (Legal Business Name): MARIO RIVERA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 17TH ST
SAN FRANCISCO CA
94114-2031
US

IV. Provider business mailing address

3850 17TH ST
SAN FRANCISCO CA
94114-2031
US

V. Phone/Fax

Practice location:
  • Phone: 628-217-5700
  • Fax:
Mailing address:
  • Phone: 628-217-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number118030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: