Provider Demographics
NPI:1952696338
Name:RIVERA, IDALIA
Entity Type:Individual
Prefix:MRS
First Name:IDALIA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4580
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-4580
Mailing Address - Country:US
Mailing Address - Phone:787-896-8784
Mailing Address - Fax:
Practice Address - Street 1:CALLE EMILIO RUIZ # 21
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-896-8784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist