Basic Information
Provider Information | |||||||||
NPI: | 1265023501 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVA | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1744 E MCANDREWS RD STE D | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975045576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414140362 | ||||||||
FaxNumber: | 5412002269 | ||||||||
Practice Location | |||||||||
Address1: | 547 E PINE ST STE 102 | ||||||||
Address2: |   | ||||||||
City: | CENTRAL POINT | ||||||||
State: | OR | ||||||||
PostalCode: | 975022444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412454444 | ||||||||
FaxNumber: | 5412454443 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2021 | ||||||||
LastUpdateDate: | 01/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 24528 | OR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 24528 | 01 | OR | OREGON HEALTH DEPARTMENT | OTHER |