Provider Demographics
NPI:1255895876
Name:RIVAS, ALEJANDRO RAMON
Entity type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:RAMON
Last Name:RIVAS
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 1:1460 MANHATAS TRL
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-3629
Mailing Address - Country:US
Mailing Address - Phone:847-428-0926
Mailing Address - Fax:
Practice Address - Street 1:1460 MANHATAS TRL
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-3629
Practice Address - Country:US
Practice Address - Phone:847-428-0926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR120-0169-81362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer