Provider Demographics
NPI:1003474768
Name:RIVERA, MAGAN (LPTA)
Entity Type:Individual
Prefix:
First Name:MAGAN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:MI
Mailing Address - Zip Code:49021-1336
Mailing Address - Country:US
Mailing Address - Phone:269-924-7174
Mailing Address - Fax:
Practice Address - Street 1:212 W CAROLINE ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:MI
Practice Address - Zip Code:49021-1336
Practice Address - Country:US
Practice Address - Phone:269-924-7174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003868225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI19514952Medicaid