Provider Demographics
NPI:1134581002
Name:RIVERA, EDGAR FRANCISCO
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:FRANCISCO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83912 AVENUE 45 STE 9
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3338
Mailing Address - Country:US
Mailing Address - Phone:760-773-6735
Mailing Address - Fax:760-347-8507
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-773-6735
Practice Address - Fax:760-347-8507
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI06870217101YA0400X
CAB0000620320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1134581002Medicaid