Provider Demographics
NPI:1003521477
Name:FREDERICK, RIVERS J IV
Entity Type:Individual
Prefix:
First Name:RIVERS
Middle Name:J
Last Name:FREDERICK
Suffix:IV
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 1:4747 EARHART BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-1747
Mailing Address - Country:US
Mailing Address - Phone:504-731-1607
Mailing Address - Fax:504-910-3065
Practice Address - Street 1:4747 EARHART BLVD STE G
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-1747
Practice Address - Country:US
Practice Address - Phone:504-731-1607
Practice Address - Fax:504-910-3065
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator