Healthcare Provider Details

I. General information

NPI: 1144490905
Provider Name (Legal Business Name): STACIE LYNNE RIVERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2008
Last Update Date: 03/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6795 EDMOND ST SUITE 210
LAS VEGAS NV
89118-3505
US

IV. Provider business mailing address

PO BOX 370549
LAS VEGAS NV
89137-0549
US

V. Phone/Fax

Practice location:
  • Phone: 702-524-2928
  • Fax:
Mailing address:
  • Phone: 702-524-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number5243
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: