Provider Demographics
NPI:1326119660
Name:RIVERA, LUIS ALFREDO JR (PT)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ALFREDO
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:403 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3514
Mailing Address - Country:US
Mailing Address - Phone:262-643-4771
Mailing Address - Fax:
Practice Address - Street 1:2615 N DOWNER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4245
Practice Address - Country:US
Practice Address - Phone:414-962-4400
Practice Address - Fax:414-962-5674
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016815225100000X
WI11189-242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic