Provider Demographics
NPI:1811579659
Name:RIZAL, IVAN JERICK (OTR)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:JERICK
Last Name:RIZAL
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 HICKORY AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-8178
Mailing Address - Country:US
Mailing Address - Phone:956-789-1650
Mailing Address - Fax:
Practice Address - Street 1:4004 N JACKSON RD
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-4962
Practice Address - Country:US
Practice Address - Phone:956-463-3887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120927225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics