Provider Demographics
NPI:1679288393
Name:RIVERA REYES, NICOLLE MARIE (DC)
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:MARIE
Last Name:RIVERA REYES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 BOONE ST STE C
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-5780
Mailing Address - Country:US
Mailing Address - Phone:337-377-0477
Mailing Address - Fax:337-404-1207
Practice Address - Street 1:1603 BOONE ST STE C
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5780
Practice Address - Country:US
Practice Address - Phone:337-377-0477
Practice Address - Fax:337-404-1207
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1973OtherCHIROPRACTOR