Provider Demographics
NPI:1922640788
Name:RIVERO-PENA, CARLOS MARCIAL
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MARCIAL
Last Name:RIVERO-PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4763 E HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6921
Mailing Address - Country:US
Mailing Address - Phone:702-906-9213
Mailing Address - Fax:
Practice Address - Street 1:4550 W OAKEY BLVD STE 111-O
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1581
Practice Address - Country:US
Practice Address - Phone:702-861-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1821520016Medicaid