Provider Demographics
NPI:1184979247
Name:RIVERA, RAYMOND (PT)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BATES ST
Mailing Address - Street 2:STE. 201
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7637
Mailing Address - Country:US
Mailing Address - Phone:207-795-2122
Mailing Address - Fax:207-795-2589
Practice Address - Street 1:77 BATES ST
Practice Address - Street 2:STE. 201
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7637
Practice Address - Country:US
Practice Address - Phone:207-795-2122
Practice Address - Fax:207-795-2589
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist