Provider Demographics
NPI:1407429780
Name:RIVERS, SIDIQUE
Entity Type:Individual
Prefix:
First Name:SIDIQUE
Middle Name:
Last Name:RIVERS
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 1:600 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-1645
Mailing Address - Country:US
Mailing Address - Phone:240-838-9608
Mailing Address - Fax:
Practice Address - Street 1:600 63RD ST
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-1645
Practice Address - Country:US
Practice Address - Phone:240-838-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health