1871044479 NPI number — MARIA DEL CARMEN RIVERA MEDINA

Table of content: (NPI 1871044479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871044479 NPI number — MARIA DEL CARMEN RIVERA MEDINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIA DEL CARMEN RIVERA MEDINA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1871044479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQ
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-743-3900
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE MADERO 1189 1
Provider Second Line Business Practice Location Address:
2A SECCION ZONA CENTRO
Provider Business Practice Location Address City Name:
MEXICALI
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
21100
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
686-553-5015
Provider Business Practice Location Address Fax Number:
866-272-6924
Provider Enumeration Date:
10/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RIVERA MEDINA
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
DEL CARMEN
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
686-553-5015

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1324321 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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