Healthcare Provider Details

I. General information

NPI: 1730323973
Provider Name (Legal Business Name): VICROR RIVERA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S TELSHOR BLVD SUITE 107
LAS CRUCES NM
88011-4907
US

IV. Provider business mailing address

2521 N MAIN UNIT 1 - 173
LAS CRUCES NM
88001-1154
US

V. Phone/Fax

Practice location:
  • Phone: 575-571-3595
  • Fax:
Mailing address:
  • Phone: 575-571-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: