Provider Demographics
NPI:1558965434
Name:VIVEROS, MAIRA
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:
Last Name:VIVEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 W BETZ RD APT 18106
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-5267
Mailing Address - Country:US
Mailing Address - Phone:509-551-0602
Mailing Address - Fax:
Practice Address - Street 1:1090 W BETZ RD APT 18106
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-5267
Practice Address - Country:US
Practice Address - Phone:509-551-0602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer