Provider Demographics
NPI:1003458019
Name:RIVERA, EDDYLANE ROSIO
Entity type:Individual
Prefix:
First Name:EDDYLANE
Middle Name:ROSIO
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDDYLANE
Other - Middle Name:ROSIO
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDDYLANE RYAN
Mailing Address - Street 1:3651 BELL BLVD STE 209
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2025
Mailing Address - Country:US
Mailing Address - Phone:718-819-8623
Mailing Address - Fax:347-836-8305
Practice Address - Street 1:3651 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2169
Practice Address - Country:US
Practice Address - Phone:718-819-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator