Provider Demographics
NPI:1508142902
Name:RIVERA, MICHAEL GAMBOA (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GAMBOA
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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Mailing Address - Street 1:1100 MELODY LN
Mailing Address - Street 2:STE 124
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5205
Mailing Address - Country:US
Mailing Address - Phone:217-257-5283
Mailing Address - Fax:
Practice Address - Street 1:2117 STARLIGHT DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357-0890
Practice Address - Country:US
Practice Address - Phone:217-257-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA41337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist