Healthcare Provider Details

I. General information

NPI: 1265234603
Provider Name (Legal Business Name): MARK ANTHONY RIVERS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 SOUTH AVE APT 301
BOARDMAN OH
44512-3658
US

IV. Provider business mailing address

6300 SOUTH AVE APT 301
BOARDMAN OH
44512-3658
US

V. Phone/Fax

Practice location:
  • Phone: 206-538-9984
  • Fax:
Mailing address:
  • Phone: 206-538-9984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: