Healthcare Provider Details

I. General information

NPI: 1730742925
Provider Name (Legal Business Name): TRISTYN ROSE RIVERA RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 AVENUE OF THE CITIES
MOLINE IL
61265-4544
US

IV. Provider business mailing address

2815 24TH AVE
MOLINE IL
61265-4240
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-0200
  • Fax:
Mailing address:
  • Phone: 309-236-6134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.007703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: