Provider Demographics
NPI:1144001421
Name:RIVERA, KEVIN G (CCHT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:RIVERA
Suffix:
Gender:M
Credentials:CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N CUSTER RD APT 3114
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3482
Mailing Address - Country:US
Mailing Address - Phone:469-816-1976
Mailing Address - Fax:
Practice Address - Street 1:925 W EXCHANGE PKWY
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7016
Practice Address - Country:US
Practice Address - Phone:800-881-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11432408132472R0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis