MEDICARE: ERNEST J RIVERA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	MFC9494	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MFC9494	OTHER	CA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1003908823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERNEST J RIVERA PH.D.

Provider Business Mailing Address
First Line	:	1623 PARAMOUNT BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-2133
Country	:	US
Telephone Number	:	323-722-8744
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 PARAMOUNT BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-2133
Country	:	US
Telephone Number	:	323-722-8744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	11/02/2007

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