Healthcare Provider Details

I. General information

NPI: 1093215667
Provider Name (Legal Business Name): LAVARN RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4904 CHURCH AVE
BROOKLYN NY
11203-3406
US

IV. Provider business mailing address

4904 CHURCH AVE
BROOKLYN NY
11203-3406
US

V. Phone/Fax

Practice location:
  • Phone: 718-581-6060
  • Fax:
Mailing address:
  • Phone: 718-581-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number22CA1064747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: