Provider Demographics
NPI:1225878861
Name:RIVERA, BRIAN (LMT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N CARLL AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2238
Mailing Address - Country:US
Mailing Address - Phone:631-482-8829
Mailing Address - Fax:631-482-8832
Practice Address - Street 1:130 N CARLL AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2238
Practice Address - Country:US
Practice Address - Phone:631-482-8829
Practice Address - Fax:631-482-8832
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033468225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty