Provider Demographics
NPI:1740212356
Name:RIVERA, AILENE BUNDALIAN (RPT)
Entity Type:Individual
Prefix:
First Name:AILENE
Middle Name:BUNDALIAN
Last Name:RIVERA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11024 BALBOA BLVD
Mailing Address - Street 2:504
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5007
Mailing Address - Country:US
Mailing Address - Phone:818-634-6328
Mailing Address - Fax:818-785-9332
Practice Address - Street 1:1711 W TEMPLE ST # 2056
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:818-634-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT286312251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28631BMedicare PIN