Healthcare Provider Details

I. General information

NPI: 1003710765
Provider Name (Legal Business Name): JOSE JUAN RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 NORTON ST
LOMBARD IL
60148-4045
US

IV. Provider business mailing address

750 NORTON ST
LOMBARD IL
60148-4045
US

V. Phone/Fax

Practice location:
  • Phone: 773-632-8685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number191821
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: