MEDICARE: LOREDANA RENAE RIVERS OTA

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	224Z00000X	Occupational Therapy Assistant	OT-A1823	AR

General Provider Information

NPI Number	:	1952059974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOREDANA RENAE RIVERS OTA

Provider Business Mailing Address
First Line	:	365 SWEET GUM ACRES RD
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730
Country	:	US
Telephone Number	:	870-918-9183
Fax Number	:

Provider Business Practice Location Address
First Line	:	365 SWEET GUM ACRES RD
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-2167
Country	:	US
Telephone Number	:	870-918-9183
Fax Number	:

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

Provider Enumeration Date	:	03/17/2022
Last Update Date	:	03/17/2022

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Directions to “ LOREDANA RENAE RIVERS OTA” Practice Location

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