Provider Demographics
NPI:1336101427
Name:RIVERA, JOSE ANTONIO JR
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:RIVERA
Suffix:JR
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 1:203 DOGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:SC
Mailing Address - Zip Code:29030-9552
Mailing Address - Country:US
Mailing Address - Phone:803-531-6005
Mailing Address - Fax:
Practice Address - Street 1:2323 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2042
Practice Address - Country:US
Practice Address - Phone:803-531-6005
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00009171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist