Provider Demographics
NPI:1043470925
Name:RIVERA MEDICAL CLINIC & DIAGNOSTIC CENTER
Entity type:Organization
Organization Name:RIVERA MEDICAL CLINIC & DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOVITO
Authorized Official - Middle Name:SAGUN
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:6375-551-6368
Mailing Address - Street 1:35 SAN JOSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALAMINOS
Mailing Address - State:PANGASINAN
Mailing Address - Zip Code:2404
Mailing Address - Country:PH
Mailing Address - Phone:6375-551-6368
Mailing Address - Fax:
Practice Address - Street 1:35 SAN JOSE DRIVE
Practice Address - Street 2:
Practice Address - City:ALAMINOS
Practice Address - State:PANGASINAN
Practice Address - Zip Code:2404
Practice Address - Country:PH
Practice Address - Phone:6375-551-6368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ80549261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094OtherINTERNATIONAL SOS