Provider Demographics
NPI:1457050163
Name:RIVERA, LANCE GABRIEL
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:GABRIEL
Last Name:RIVERA
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 1:4602 ELM POINT DR
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-4334
Mailing Address - Country:US
Mailing Address - Phone:214-293-0728
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty