1508226101 NPI number — DR. AGUSTIN RIVERA M.D; MC; CLERGY

Table of content: DR. AGUSTIN RIVERA M.D; MC; CLERGY (NPI 1508226101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508226101 NPI number — DR. AGUSTIN RIVERA M.D; MC; CLERGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
AGUSTIN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D; MC; CLERGY
Provider Gender Code:
M

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:
1508226101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17906 WOODCREST WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34714-5906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-420-9899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 E LANCASTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32809-6689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-582-9899
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2016

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: 101YP1600X , with the licence number:  1702-002 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 557 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: PHM 1453 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 805036272 . This is a "FUNCTIONAL ASSESSMENT RATING SCALE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1001A-1005 . This is a "TRAUMATOLOGY" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 802042738 . This is a "CHILDREN'S FUNCTIONAL ASSESMENT RATING SCALE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: CEP 15893 . This is a "SEXUAL ASSAULT FORENSIC EXAMINER TRAINING" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: MFT 557 . This is a "MARRIAGE AND FAMILY COUNSELING" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: XXXX . This is a "MEDICAL DOCTOR" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: COURSE 20-32231 . This is a "QUALIFIED SUPERVISOR TRAINING" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P852 NAADA . This is a "PROFESSIONAL CERTIFICATE IN COUNSELING ADDICTIVE DISORDERS AND MENTAL HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PHM 1453 . This is a "MENTAL HEALTH COUNSELOR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2543 . This is a "DIPLOMATE AMERICAN BOARD OF SEXOLOGY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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