Healthcare Provider Details

I. General information

NPI: 1871073668
Provider Name (Legal Business Name): PETER JULIAN RIVERA MENORCA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MIEL DE LUNA AVE
TUCUMCARI NM
88401-3810
US

IV. Provider business mailing address

415 E WASHINGTON AVE APT 6
TUCUMCARI NM
88401-3812
US

V. Phone/Fax

Practice location:
  • Phone: 575-461-7230
  • Fax:
Mailing address:
  • Phone: 954-870-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1287167
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License NumberPT-2023-2047
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: