1588692206 NPI number — MRS. ISAMAR VANESSA RIVERA PT

Table of content: MRS. ISAMAR VANESSA RIVERA PT (NPI 1588692206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588692206 NPI number — MRS. ISAMAR VANESSA RIVERA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
ISAMAR
Provider Middle Name:
VANESSA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588692206
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9926 PORTOFINO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32832-5630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-765-6145
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HC 3 BOX 12000
Provider Second Line Business Practice Location Address:
BO. YEGUADA
Provider Business Practice Location Address City Name:
CAMUY
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00627-9754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-447-8064
Provider Business Practice Location Address Fax Number:
800-730-6853
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1310 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 020778800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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