Provider Demographics
NPI:1679153480
Name:RICHARD RIVERA MDPC
Entity type:Organization
Organization Name:RICHARD RIVERA MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:R
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-564-9400
Mailing Address - Street 1:127 JUSTICE CENTER RD STE J
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9378
Mailing Address - Country:US
Mailing Address - Phone:719-269-1136
Mailing Address - Fax:719-269-1186
Practice Address - Street 1:127 JUSTICE CENTER RD STE J
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9378
Practice Address - Country:US
Practice Address - Phone:719-269-1136
Practice Address - Fax:719-269-1186
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD RIVERA MDPC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61024821Medicaid