Provider Demographics
NPI:1427507862
Name:RIVERA, HERIBERTO
Entity type:Individual
Prefix:
First Name:HERIBERTO
Middle Name:
Last Name:RIVERA
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:QUINTA REAL CALLE REY DAVID
Mailing Address - Street 2:9306
Mailing Address - City:TOA BAJA
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00949
Mailing Address - Country:UM
Mailing Address - Phone:787-392-2320
Mailing Address - Fax:
Practice Address - Street 1:QUINTA REAL CALLE REY DAVID
Practice Address - Street 2:9306
Practice Address - City:TOA BAJA
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00949
Practice Address - Country:UM
Practice Address - Phone:787-392-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1996084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist