Basic Information
| Provider Information | |||||||||
| NPI: | 1710172093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOMICILLIARY SERVICE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DR. RIVERO AND ASSOCIATES II | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1513 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696857020 | ||||||||
| FaxNumber: | 2149208446 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696857020 | ||||||||
| FaxNumber: | 2149208446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIVERO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4695959475 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DO1083 | 01 | RAILROAD MEDICARE PTAN | OTHER |