Provider Demographics
NPI:1437559101
Name:RIVAS, IRENE LISA
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:LISA
Last Name:RIVAS
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 1:831 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2535
Mailing Address - Country:US
Mailing Address - Phone:951-847-3636
Mailing Address - Fax:
Practice Address - Street 1:831 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2535
Practice Address - Country:US
Practice Address - Phone:951-847-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-R1209070829171M00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARI-R1209070829OtherCAADE