Healthcare Provider Details

I. General information

NPI: 1174205827
Provider Name (Legal Business Name): SAMANTHA A RIVERA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 WEIMER RD
TAOS NM
87571-6201
US

IV. Provider business mailing address

1393 WEIMER RD
TAOS NM
87571-6201
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5681
  • Fax:
Mailing address:
  • Phone: 575-758-8651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1377
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: