Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | MFC9494 | CA |
Y | 103T00000X | Psychologist | MFC9494 | CA |
NPI | 1003908823 |
---|---|
Provider Name | Ernest J Rivera |
First Address | Montebello, CA 90640-2133 |
Second Address | Montebello, CA 90640-2133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2006 |
Last Update Date | 02/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MFC9494 | BLUE CROSS BLUE SHIELD (01) | CA |