Healthcare Provider Details

I. General information

NPI: 1447389416
Provider Name (Legal Business Name): MARISOL RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

D12 CAMINO DEL CHALET QUINTA DEL RIO
BAYAMON PR
00961-3012
US

IV. Provider business mailing address

D12 CAMINO DEL CHALET QUINTA DEL RIO
BAYAMON PR
00961-3012
US

V. Phone/Fax

Practice location:
  • Phone: 787-207-1265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number6075
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: