1437814167 NPI number — RENE RIVERA COLLAZO SR.

Table of content: RENE RIVERA COLLAZO SR. (NPI 1437814167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437814167 NPI number — RENE RIVERA COLLAZO SR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA COLLAZO
Provider First Name:
RENE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
Provider Gender Code:
M

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:
1437814167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 CALLE HECTOR PANTOJAS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VEGA BAJA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00693-4031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-515-0038
Provider Business Mailing Address Fax Number:
787-269-5686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SANTA ROSA MALL
Provider Second Line Business Practice Location Address:
SUITE 218
Provider Business Practice Location Address City Name:
BAYAMON
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-798-3967
Provider Business Practice Location Address Fax Number:
787-269-5686
Provider Enumeration Date:
11/08/2021

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: 225100000X , with the licence number:  4584 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4584 . This is a "LICENCIA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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