Healthcare Provider Details

I. General information

NPI: 1689380826
Provider Name (Legal Business Name): SHANE AUSTIN RIVERA GENRAL CONTRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SHANE AUSTIN RIVERA SR REMODELING

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 S STEELE ST
CENTENNIAL CO
80122-1839
US

IV. Provider business mailing address

6810 S STEELE ST
CENTENNIAL CO
80122-1839
US

V. Phone/Fax

Practice location:
  • Phone: 172-053-0412
  • Fax:
Mailing address:
  • Phone: 720-530-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: