Provider Demographics
NPI:1417241217
Name:RIVERA FUENTES, RITA O
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:O
Last Name:RIVERA FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 734
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705
Mailing Address - Country:US
Mailing Address - Phone:787-325-7095
Mailing Address - Fax:787-735-7613
Practice Address - Street 1:CALLE JOSE C VAZQUEZ 62
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-325-7095
Practice Address - Fax:787-735-7613
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1812061133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist