Provider Demographics
NPI:1609826155
Name:RIVERA, KENNETH DAVID
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
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 1:197 SICKLES AVE
Mailing Address - Street 2:APT. B11
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:197 SICKLES AVE
Practice Address - Street 2:APT. B11
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1810
Practice Address - Country:US
Practice Address - Phone:845-988-6303
Practice Address - Fax:845-480-5567
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor