MEDICARE: TONY RIVERA ATC

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	207PS0010X	Sports Medicine (Emergency Medicine) Physician	2000058675	CA

General Provider Information

NPI Number	:	1508712043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONY RIVERA ATC

Provider Business Mailing Address
First Line	:	3169 JUANITA ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-4513
Country	:	US
Telephone Number	:	909-641-1711
Fax Number	:

Provider Business Practice Location Address
First Line	:	3169 JUANITA ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-4513
Country	:	US
Telephone Number	:	909-641-1711
Fax Number	:

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

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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