Provider Demographics
NPI:1750656138
Name:RIVERA, ANGIE GAUDETH
Entity Type:Individual
Prefix:MISS
First Name:ANGIE
Middle Name:GAUDETH
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6606 ARBUTUS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5222
Mailing Address - Country:US
Mailing Address - Phone:323-633-4301
Mailing Address - Fax:
Practice Address - Street 1:11741 TELEGRAPH RD STE G
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3687
Practice Address - Country:US
Practice Address - Phone:562-942-8256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator