Provider Demographics
NPI:1083167373
Name:RIVAS, JOSE ANGEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:RIVAS
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 1:60 RANGE RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-9028
Mailing Address - Country:US
Mailing Address - Phone:505-620-6676
Mailing Address - Fax:
Practice Address - Street 1:60 RANGE RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-9028
Practice Address - Country:US
Practice Address - Phone:505-620-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5113094842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer