Basic Information
| Provider Information | |||||||||
| NPI: | 1679797187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | LISSETTE | ||||||||
| MiddleName: | ACOSTA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20897 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009280897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877608405 | ||||||||
| FaxNumber: | 7877608405 | ||||||||
| Practice Location | |||||||||
| Address1: | G 10 PERIFERAL AVE | ||||||||
| Address2: | COOP CUIDAD UNIVERSITARIA | ||||||||
| City: | TRUJILLO ALTO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009762104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877608405 | ||||||||
| FaxNumber: | 7877608405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 133 | PR | Y | Other Service Providers | Specialist |
No ID Information.