# RIVERA MEDICAL OFFICE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Renato B. Rivera, MD, LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114073756
- **Authorized official:** LISA R RIVERA (OFFICE MANAGER)
- **Authorized official phone:** (618) 594-3613

## Contact information

- **Practice address:** 1110 MULLIKEN ST, CARLYLE, IL 62231-1233
- **Practice address phone:** (618) 594-3613
- **Practice address fax:** (681) 594-4799
- **Mailing address:** 1110 MULLIKEN ST, PO BOX 147, CARLYLE, IL 62231-1233
- **Mailing address phone:** (618) 594-3613
- **Mailing address fax:** (681) 594-4799

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 036096480 | IL | — |
| 208000000X | Pediatrics Physician | 036096480 | IL | — |
| 261QR1300X | Rural Health Clinic/Center | 036-096480 | IL | Yes |

## Other

- **Enumeration date:** 01/26/2007
- **Last updated:** 05/16/2008