Provider Demographics
NPI:1275219313
Name:LA RIVA, JUAN LUIS (SA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:LUIS
Last Name:LA RIVA
Suffix:
Gender:M
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19015 S JODI RD STE H
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:866-787-4452
Mailing Address - Fax:
Practice Address - Street 1:19015 S JODI RD STE H
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:866-787-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238.000786OtherILLINOIS STATE LICENSE