Provider Demographics
NPI:1548729759
Name:RIVERA MEDINA, GEORGE ALFRED (DC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ALFRED
Last Name:RIVERA MEDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 ROBBINS ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2762
Mailing Address - Country:US
Mailing Address - Phone:203-573-8577
Mailing Address - Fax:
Practice Address - Street 1:255 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2762
Practice Address - Country:US
Practice Address - Phone:203-573-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2141OtherCHIROPRACTIC