=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720742828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA PUPO-RIVERO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 W GREENLAWN AVE STE 200
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48910-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-657-2638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 W GREENLAWN AVE STE 200
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48910-2889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-657-2638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156F00000X
-----------------------------------------------------
Taxonomy Name | Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------