=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538354717
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADRIAN RIVAS I.D.C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 10/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 GATOR BLVD BUILDING 3808
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23521-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-462-1056
-----------------------------------------------------
Fax | 757-462-3111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 GATOR BLVD BUILDING 3808
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23521-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-462-1056
-----------------------------------------------------
Fax | 757-462-3111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1710I1002X
-----------------------------------------------------
Taxonomy Name | Independent Duty Corpsman
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------