Provider Demographics
NPI:1497442446
Name:RIVERA, VICTOR M
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
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 1:5000 5TH AVE
Mailing Address - Street 2:ASSISTIVE TECH LAB BLD.12 3RD FLR
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141
Mailing Address - Country:US
Mailing Address - Phone:708-202-4879
Mailing Address - Fax:
Practice Address - Street 1:5000 5TH AVE
Practice Address - Street 2:ASSISTIVE TECH LAB BLD.12 3RD FLR
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILNA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation