=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538504071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. ELIONEXSIS RIVERA RODRIGUEZ, CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2013
-----------------------------------------------------
Last Update Date | 05/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVE. EMERITO ESTRADA 1001 ALTOS
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-280-4889
-----------------------------------------------------
Fax | 787-280-4889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | C14 CALLE 4 URB. VENTURINI
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-2708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-280-4889
-----------------------------------------------------
Fax | 787-280-4889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN/PRESIDENT
-----------------------------------------------------
Name | DR. ELIONEXSIS RIVERA RODRIGUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-280-4889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 10898
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------