MEDICARE: RIVERA OPTOMETRIC GROUP P.C.

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	152W00000X	Optometrist	2011037045	MO

General Provider Information

NPI Number	:	1831455179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERA OPTOMETRIC GROUP P.C.

Provider Business Mailing Address
First Line	:	PO BOX 1701
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-7001
Country	:	US
Telephone Number	:	417-204-2320
Fax Number	:

Provider Business Practice Location Address
First Line	:	1310 PREACHER ROE BLVD # HGW
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-2938
Country	:	US
Telephone Number	:	417-257-2807
Fax Number	:	417-257-2815

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANGEL KEITH RIVERA
Credential	:	O.D.
Telephone Number	:	417-204-2320

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	04/10/2012

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