Provider Demographics
NPI:1285288985
Name:RIVERA, ERIC SEAN (LICENSED DISPENSER)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:SEAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LICENSED DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 HUNTINGDON PIKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-6113
Mailing Address - Country:US
Mailing Address - Phone:215-947-2606
Mailing Address - Fax:
Practice Address - Street 1:2555 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-6113
Practice Address - Country:US
Practice Address - Phone:215-947-2606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF30549237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF03549OtherPA DEPT OF HEALTH
PAF03549Medicaid