Healthcare Provider Details

I. General information

NPI: 1194268599
Provider Name (Legal Business Name): RIBERA MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6341 RIVERSIDE PLAZA LN NW SUITE A
ALBUQUERQUE NM
87120-2646
US

IV. Provider business mailing address

6341 RIVERSIDE PLAZA LN NW SUITE A
ALBUQUERQUE NM
87120-2646
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-8920
  • Fax: 866-406-4513
Mailing address:
  • Phone: 505-226-8920
  • Fax: 866-406-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberRN-79594
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD-88-97
License Number StateNM

VIII. Authorized Official

Name: MRS. OLGA Z. LUCERO
Title or Position: MANAGER-OWNER
Credential: RN
Phone: 505-226-8920