Healthcare Provider Details

I. General information

NPI: 1275912958
Provider Name (Legal Business Name): RIVERA MHT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 HERITAGE DR
MCKINNEY TX
75069-3256
US

IV. Provider business mailing address

1515 HERITAGE DR
MCKINNEY TX
75069-3256
US

V. Phone/Fax

Practice location:
  • Phone: 972-616-4932
  • Fax: 877-489-3949
Mailing address:
  • Phone: 972-616-4932
  • Fax: 877-489-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG1757
License Number StateTX

VIII. Authorized Official

Name: DIEGO RIVERA
Title or Position: OWNER / PRESIDENT
Credential: MD
Phone: 806-723-8881