Provider Demographics
NPI:1346630886
Name:RIVERA, JOSE
Entity Type:Individual
Prefix:MR
First Name:JOSE
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 1:1325 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-4360
Mailing Address - Country:US
Mailing Address - Phone:818-599-0893
Mailing Address - Fax:818-252-7552
Practice Address - Street 1:1325 4TH ST.
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-4360
Practice Address - Country:US
Practice Address - Phone:818-599-0893
Practice Address - Fax:818-252-7552
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program