Healthcare Provider Details

I. General information

NPI: 1487286449
Provider Name (Legal Business Name): LUZ RAQUEL RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 BERGEN AVE FL 4
BRONX NY
10455-1368
US

IV. Provider business mailing address

555 BERGEN AVE
BRONX NY
10455-1368
US

V. Phone/Fax

Practice location:
  • Phone: 718-742-8526
  • Fax:
Mailing address:
  • Phone: 718-742-8526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number467315-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: