Provider Demographics
NPI:1801507546
Name:GONZALEZ RIVERA, KENNY
Entity type:Individual
Prefix:MR
First Name:KENNY
Middle Name:
Last Name:GONZALEZ 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:HC 57 BOX 10703
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9830
Mailing Address - Country:US
Mailing Address - Phone:787-234-9075
Mailing Address - Fax:
Practice Address - Street 1:830 STREET 857
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987
Practice Address - Country:US
Practice Address - Phone:787-701-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist