Provider Demographics
NPI:1467017962
Name:RIQUELME, MARA (PT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:RIQUELME
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69-31 CALLE 57
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-4933
Mailing Address - Country:US
Mailing Address - Phone:787-463-8712
Mailing Address - Fax:
Practice Address - Street 1:COMUNIDAD PARQUE ESCORIAL BO SAN ANTON
Practice Address - Street 2:CARR 3 AVE 65 DE INFANTERIA INTER CARR 887
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00986
Practice Address - Country:US
Practice Address - Phone:787-757-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist