Healthcare Provider Details

I. General information

NPI: 1104559665
Provider Name (Legal Business Name): HARRY G RIVERA ROSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 AVE JESUS T PINERO STE 119
CAYEY PR
00736-5578
US

IV. Provider business mailing address

HC 1 BOX 6697
AIBONITO PR
00705-9767
US

V. Phone/Fax

Practice location:
  • Phone: 939-257-0086
  • Fax:
Mailing address:
  • Phone: 939-257-0086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16049
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: