Provider Demographics
NPI:1689256935
Name:RIVAS, JESSE JR (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:RIVAS
Suffix:JR
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34302 LAURA WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1830
Mailing Address - Country:US
Mailing Address - Phone:760-848-5737
Mailing Address - Fax:
Practice Address - Street 1:30 HUNTER LN
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2400
Practice Address - Country:US
Practice Address - Phone:800-748-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95244156163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse