Provider Demographics
NPI:1558818658
Name:RIVAS, CARLO JOSE VILLANUEVA
Entity Type:Individual
Prefix:MR
First Name:CARLO JOSE
Middle Name:VILLANUEVA
Last Name:RIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CARLO-JOSE
Other - Middle Name:VILLANUEVA
Other - Last Name:RIVAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5646 BEDELL RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3251
Mailing Address - Country:US
Mailing Address - Phone:248-854-8046
Mailing Address - Fax:
Practice Address - Street 1:17197 N LAUREL PARK DR
Practice Address - Street 2:SUITE 555
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2680
Practice Address - Country:US
Practice Address - Phone:734-779-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist