Provider Demographics
NPI:1972795607
Name:RIVERA, CHRISTIAN GABRIEL (DC)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:GABRIEL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DC
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 291794
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-1794
Mailing Address - Country:US
Mailing Address - Phone:314-609-2006
Mailing Address - Fax:
Practice Address - Street 1:1821 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2258
Practice Address - Country:US
Practice Address - Phone:314-609-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR428111N00000X
MO2006033754111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor