Provider Demographics
NPI:1437814167
Name:RIVERA COLLAZO, RENE SR
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:RIVERA COLLAZO
Suffix:SR
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 1:21 CALLE HECTOR PANTOJAS
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-4031
Mailing Address - Country:US
Mailing Address - Phone:787-515-0038
Mailing Address - Fax:787-269-5686
Practice Address - Street 1:SANTA ROSA MALL
Practice Address - Street 2:SUITE 218
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-798-3967
Practice Address - Fax:787-269-5686
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4584OtherLICENCIA