Provider Demographics
NPI:1639733512
Name:RIVERA, CRYSTAL DESERE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DESERE
Last Name:RIVERA
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 1:90 BRIARCLIFF RD APT 2
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1642
Mailing Address - Country:US
Mailing Address - Phone:774-257-2923
Mailing Address - Fax:
Practice Address - Street 1:90 BRIARCLIFF RD APT 2
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1642
Practice Address - Country:US
Practice Address - Phone:774-257-2923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program