Healthcare Provider Details

I. General information

NPI: 1285210286
Provider Name (Legal Business Name): LISA M RIVERA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2021
Last Update Date: 03/20/2021
Certification Date: 03/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11208 ARVADA AVE NE
ALBUQUERQUE NM
87112-3214
US

IV. Provider business mailing address

11208 ARVADA AVE NE
ALBUQUERQUE NM
87112-3214
US

V. Phone/Fax

Practice location:
  • Phone: 575-590-4542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT7536
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT7537
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: