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General NPI Number Information
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NPI Number | 1083167373
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Entity Type | Individual
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Provider Name | JOSE ANGEL RIVAS
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Gender | Male
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Dates
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Enumeration Date | 08/03/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 60 RANGE RD
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City | EDGEWOOD
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State | NM
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Zip | 87015-9028
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Country | US
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Telephone | 505-620-6676
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Fax |
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Provider Business Mailing Address
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Address Line | 60 RANGE RD
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City | EDGEWOOD
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State | NM
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Zip | 87015-9028
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Country | US
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Telephone | 505-620-6676
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 511309484
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License Number State | NM
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