Healthcare Provider Details

I. General information

NPI: 1649574518
Provider Name (Legal Business Name): RIVERA MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 MULLIKEN ST
CARLYLE IL
62231-1233
US

IV. Provider business mailing address

1110 MULLIKEN ST
CARLYLE IL
62231-1233
US

V. Phone/Fax

Practice location:
  • Phone: 618-594-3613
  • Fax: 618-594-4799
Mailing address:
  • Phone: 618-594-3613
  • Fax: 618-594-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036096480
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036096480
License Number StateIL

VIII. Authorized Official

Name: MRS. LISA R RIVERA
Title or Position: OFFICE MANAGER
Credential:
Phone: 618-594-3613