Provider Demographics
NPI:1679791867
Name:RIVERA, RODRIGO DYCHITAN (RPT)
Entity Type:Individual
Prefix:MR
First Name:RODRIGO
Middle Name:DYCHITAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 W PRATT ST APT 1414
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1657
Mailing Address - Country:US
Mailing Address - Phone:323-404-7443
Mailing Address - Fax:
Practice Address - Street 1:4609 MAUBERT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5308
Practice Address - Country:US
Practice Address - Phone:323-404-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist