Provider Demographics
NPI:1710289137
Name:RIVERA, MADELINE (LND)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 BOSQUE DEL RIO
Mailing Address - Street 2:APTO U-201
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-3156
Mailing Address - Country:US
Mailing Address - Phone:787-344-5224
Mailing Address - Fax:
Practice Address - Street 1:145 BOSQUE DEL RIO
Practice Address - Street 2:APTO U-201
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-3156
Practice Address - Country:US
Practice Address - Phone:787-344-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1542133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1542OtherDIETITIAN LICENSE