Provider Demographics
NPI:1356196588
Name:RIVERA, JOSUE ENMANUEL (LMT)
Entity type:Individual
Prefix:
First Name:JOSUE
Middle Name:ENMANUEL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:JOSUE
Other - Middle Name:E
Other - Last Name:CABEZAS RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBO
Mailing Address - Street 1:2130 VICKERS DR STE 119
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-8129
Mailing Address - Country:US
Mailing Address - Phone:719-828-3574
Mailing Address - Fax:
Practice Address - Street 1:2130 VICKERS DR STE 119
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8129
Practice Address - Country:US
Practice Address - Phone:719-828-3574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist