Healthcare Provider Details

I. General information

NPI: 1336101427
Provider Name (Legal Business Name): JOSE ANTONIO RIVERA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 SAINT MATTHEWS RD
ORANGEBURG SC
29118-2042
US

IV. Provider business mailing address

203 DOGWOOD ST
CAMERON SC
29030-9552
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-6005
  • Fax:
Mailing address:
  • Phone: 803-531-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number00009
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: