Healthcare Provider Details

I. General information

NPI: 1801322466
Provider Name (Legal Business Name): ROBERT JUSTIN RIVERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 SAN BERNARDINO RD
UPLAND CA
91786-4920
US

IV. Provider business mailing address

4181 TEMESCAL AVE
NORCO CA
92860-1429
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-2811
  • Fax:
Mailing address:
  • Phone: 951-751-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP29948
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: