Healthcare Provider Details

I. General information

NPI: 1760256812
Provider Name (Legal Business Name): MR. MANUEL RIVAS IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 E 55TH ST
TULSA OK
74135
US

IV. Provider business mailing address

4511 E 55TH ST
TULSA OK
74135-4301
US

V. Phone/Fax

Practice location:
  • Phone: 405-240-1793
  • Fax:
Mailing address:
  • Phone: 405-240-1793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: