Provider Demographics
NPI:1093056616
Name:RIVERA, ROBERT
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:RIVERA
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 1:38651 ERIKA LN
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-5417
Mailing Address - Country:US
Mailing Address - Phone:661-267-6225
Mailing Address - Fax:
Practice Address - Street 1:43520 DIVISION ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4089
Practice Address - Country:US
Practice Address - Phone:661-274-2527
Practice Address - Fax:661-274-9970
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633-765OtherMEDI-CAL