Provider Demographics
NPI:1073151288
Name:RIVERA, JESUS MANUEL JR (RDN, LD)
Entity Type:Individual
Prefix:MR
First Name:JESUS
Middle Name:MANUEL
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 RIVER PARK PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-4112
Mailing Address - Country:US
Mailing Address - Phone:915-222-3266
Mailing Address - Fax:915-219-8494
Practice Address - Street 1:7338 REMCON CIR STE 300
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-1637
Practice Address - Country:US
Practice Address - Phone:915-613-5580
Practice Address - Fax:915-842-0841
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82409133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered