Healthcare Provider Details

I. General information

NPI: 1326119660
Provider Name (Legal Business Name): LUIS ALFREDO RIVERA JR. P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N DOWNER AVE
MILWAUKEE WI
53211-4245
US

IV. Provider business mailing address

403 W MEQUON RD
MEQUON WI
53092-3514
US

V. Phone/Fax

Practice location:
  • Phone: 414-962-4400
  • Fax: 414-962-5674
Mailing address:
  • Phone: 262-643-4771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070016815
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11189-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: