MEDICARE: STACIE LYNNE RIVERS M.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	305R00000X	Preferred Provider Organization	5243	NV

General Provider Information

NPI Number	:	1144490905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE LYNNE RIVERS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 370549
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89137-0549
Country	:	US
Telephone Number	:	702-524-2928
Fax Number	:

Provider Business Practice Location Address
First Line	:	6795 EDMOND ST
Second Line	:	SUITE 210
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3505
Country	:	US
Telephone Number	:	702-524-2928
Fax Number	:

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

Provider Enumeration Date	:	03/08/2008
Last Update Date	:	03/08/2008

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