Basic Information
| Provider Information | |||||||||
| NPI: | 1689381824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | MARVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 LAS PALMAS ENTRADA AVE APT 2126 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890125631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692880058 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2850 W HORIZON RIDGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023138446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.