Provider Demographics
NPI:1770053902
Name:RIVERA, ANTONIO (DC)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 DILLARD LOOP, SUITE C
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607
Mailing Address - Country:US
Mailing Address - Phone:318-453-2963
Mailing Address - Fax:
Practice Address - Street 1:2625 DILLARD LOOP, SUITE C
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607
Practice Address - Country:US
Practice Address - Phone:318-453-2963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1836111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor