Provider Demographics
NPI:1689060923
Name:RIVERS, JUANITA
Entity Type:Individual
Prefix:MS
First Name:JUANITA
Middle Name:
Last Name:RIVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JUANITA
Other - Middle Name:
Other - Last Name:RIVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:SC
Mailing Address - Zip Code:29160-0335
Mailing Address - Country:US
Mailing Address - Phone:803-378-6146
Mailing Address - Fax:803-568-0001
Practice Address - Street 1:145 FAITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:SC
Practice Address - Zip Code:29160-9760
Practice Address - Country:US
Practice Address - Phone:803-378-6146
Practice Address - Fax:803-568-0001
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007236626172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver