Provider Demographics
NPI:1386409480
Name:RIVERA, SAMUEL (RDN)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 EXETER AVE FRNT
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:PA
Mailing Address - Zip Code:18643-1254
Mailing Address - Country:US
Mailing Address - Phone:845-476-4262
Mailing Address - Fax:
Practice Address - Street 1:946 EXETER AVE FRNT
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:PA
Practice Address - Zip Code:18643-1254
Practice Address - Country:US
Practice Address - Phone:845-476-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN008279133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered