Provider Demographics
NPI:1053967521
Name:RIVARDE, MIA ARIEL
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:ARIEL
Last Name:RIVARDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 DECATUR ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-1502
Mailing Address - Country:US
Mailing Address - Phone:504-432-4069
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR STE LL105
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No174400000XOther Service ProvidersSpecialist