MEDICARE: ANTONIO RIVAS

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1265915300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIO RIVAS

Provider Business Mailing Address
First Line	:	206 N JACKSON ST STE 202
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-4330
Country	:	US
Telephone Number	:	818-241-6780
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 CROW CANYON PL. #205
Second Line	:
City	:	SAN RAMON
State	:	UT
Zip	:	84101-8410
Country	:	US
Telephone Number	:	818-241-6780
Fax Number	:

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

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	09/14/2018

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Directions to “ ANTONIO RIVAS ” Practice Location

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