Provider Demographics
NPI:1376128538
Name:DE LA RIVA, SELENA (TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:DE LA RIVA
Suffix:
Gender:F
Credentials:TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-4024
Mailing Address - Country:US
Mailing Address - Phone:708-343-5323
Mailing Address - Fax:
Practice Address - Street 1:1600 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-4024
Practice Address - Country:US
Practice Address - Phone:708-343-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049279949183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician