1235705336 NPI number — MRS. LISA LOUISE RIVERA CM61165804

Table of content: MRS. LISA LOUISE RIVERA CM61165804 (NPI 1235705336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235705336 NPI number — MRS. LISA LOUISE RIVERA CM61165804

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
LISA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CM61165804
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235705336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1314 BROWNE AVE APT 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-3054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-881-5307
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 HIGHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUENA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98921-0139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-865-6705
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2470A2800X , with the licence number:  CM61165804 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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