Provider Demographics
NPI:1679797187
Name:RIVERA, LISSETTE ACOSTA
Entity type:Individual
Prefix:MISS
First Name:LISSETTE
Middle Name:ACOSTA
Last Name:RIVERA
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:PO BOX 20897
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-0897
Mailing Address - Country:US
Mailing Address - Phone:787-760-8405
Mailing Address - Fax:787-760-8405
Practice Address - Street 1:G 10 PERIFERAL AVE
Practice Address - Street 2:COOP CUIDAD UNIVERSITARIA
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-2104
Practice Address - Country:US
Practice Address - Phone:787-760-8405
Practice Address - Fax:787-760-8405
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR133174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0056786Medicare ID - Type Unspecified