Provider Demographics
NPI:1437538873
Name:RIVERA, CHRISTOPHER RYAN
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RYAN
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 1:4997 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:CADDO
Mailing Address - State:OK
Mailing Address - Zip Code:74729-4214
Mailing Address - Country:US
Mailing Address - Phone:580-230-9418
Mailing Address - Fax:
Practice Address - Street 1:1760 BLEVINS RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:OK
Practice Address - Zip Code:74723-2325
Practice Address - Country:US
Practice Address - Phone:580-847-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist