Provider Demographics
NPI:1154939130
Name:JOUBERT, WIGIE RIVERA
Entity type:Individual
Prefix:
First Name:WIGIE
Middle Name:RIVERA
Last Name:JOUBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43002
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-6601
Mailing Address - Country:US
Mailing Address - Phone:939-218-5848
Mailing Address - Fax:
Practice Address - Street 1:URB COUNTRY CLUB
Practice Address - Street 2:797
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:939-218-5848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0000179175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4583516Medicaid