Provider Demographics
NPI:1780068452
Name:RIVERA, KEISHLA
Entity type:Individual
Prefix:
First Name:KEISHLA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEISHLA
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 SHAWMUT ST
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-3227
Mailing Address - Country:US
Mailing Address - Phone:617-659-7659
Mailing Address - Fax:
Practice Address - Street 1:135 SHAWMUT ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150
Practice Address - Country:US
Practice Address - Phone:617-659-7659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization