Healthcare Provider Details

I. General information

NPI: 1992973473
Provider Name (Legal Business Name): RICHARD RIVERA MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 CHINOOK LN
PUEBLO CO
81001-1850
US

IV. Provider business mailing address

1080 CHINOOK LN
PUEBLO CO
81001-1850
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-9400
  • Fax: 719-564-0497
Mailing address:
  • Phone: 719-564-9400
  • Fax: 719-564-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number19885
License Number StateCO

VIII. Authorized Official

Name: DR. RICHARD RIVERA
Title or Position: OWNER
Credential: M.D.
Phone: 719-564-9400