Healthcare Provider Details

I. General information

NPI: 1871109728
Provider Name (Legal Business Name): NICHOLAS RAY RIVELAND OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 S FITNESS PL
EAGLE ID
83616-6828
US

IV. Provider business mailing address

7458 W SAXTON DR APT 202
BOISE ID
83714-1320
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-6301
  • Fax:
Mailing address:
  • Phone: 701-330-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2273
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: