Provider Demographics
NPI:1346885035
Name:RIVERA, RAFAEL GUILLERMO IV
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:GUILLERMO
Last Name:RIVERA
Suffix:IV
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:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:DANNEMORA
Mailing Address - State:NY
Mailing Address - Zip Code:12929-0861
Mailing Address - Country:US
Mailing Address - Phone:518-492-2056
Mailing Address - Fax:
Practice Address - Street 1:17 HIGH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1595
Practice Address - Country:US
Practice Address - Phone:603-535-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program