Provider Demographics
NPI:1720215221
Name:RIVERO, SUZANNA M (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:SUZANNA
Middle Name:M
Last Name:RIVERO
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N STATE PKWY
Mailing Address - Street 2:#12
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2234
Mailing Address - Country:US
Mailing Address - Phone:309-532-0810
Mailing Address - Fax:
Practice Address - Street 1:1209 N STATE PKWY
Practice Address - Street 2:#12
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2234
Practice Address - Country:US
Practice Address - Phone:309-532-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered