Provider Demographics
NPI:1295196715
Name:RIVAS, STEPHEN FERNANDO I
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:FERNANDO
Last Name:RIVAS
Suffix:I
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 1:1024 N SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-4137
Mailing Address - Country:US
Mailing Address - Phone:773-827-1821
Mailing Address - Fax:
Practice Address - Street 1:1024 N SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-4137
Practice Address - Country:US
Practice Address - Phone:773-827-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer