Healthcare Provider Details

I. General information

NPI: 1982972063
Provider Name (Legal Business Name): ANGEL KEITH RIVERA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 PREACHER ROE BLVD # HGW
WEST PLAINS MO
65775-2938
US

IV. Provider business mailing address

PO BOX 1701
WEST PLAINS MO
65775-7001
US

V. Phone/Fax

Practice location:
  • Phone: 787-510-5403
  • Fax:
Mailing address:
  • Phone: 787-510-5403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2011037045
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: