Basic Information
| Provider Information | |||||||||
| NPI: | 1053359240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVADA | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2WEST 10TH STREET | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 FORREST AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199043483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027354900 | ||||||||
| FaxNumber: | 3027354671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0001635 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.