Provider Demographics
NPI:1760180244
Name:RIVERS, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:RIVERS
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 1:175 COUNTRY CLUB DR STE D
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9054
Mailing Address - Country:US
Mailing Address - Phone:770-907-9400
Mailing Address - Fax:770-907-1213
Practice Address - Street 1:175 COUNTRY CLUB DR STE D
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9054
Practice Address - Country:US
Practice Address - Phone:770-907-9400
Practice Address - Fax:770-907-1213
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology