Basic Information
| Provider Information | |||||||||
| NPI: | 1235622333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | EDITH | ||||||||
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| Credential: | IDMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4803 HAMILTON WOLFE RD APT 120 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108339353 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3600 ROGER BROOKE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109169900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2018 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1003X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians |
No ID Information.