Healthcare Provider Details

I. General information

NPI: 1265420053
Provider Name (Legal Business Name): REBECCA JEAN REILLY-NIVERS D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12705 RIO BRAVO ST
ROSHARON TX
77583-4073
US

IV. Provider business mailing address

12705 RIO BRAVO ST
ROSHARON TX
77583-4073
US

V. Phone/Fax

Practice location:
  • Phone: 281-369-7064
  • Fax: 281-369-7073
Mailing address:
  • Phone: 832-526-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1618
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: