Provider Demographics
NPI:1003329269
Name:REVILLA RODRIGUEZ, VIVIAN (SA-C)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:REVILLA RODRIGUEZ
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21501 SW 113TH AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2723
Mailing Address - Country:US
Mailing Address - Phone:786-499-4276
Mailing Address - Fax:
Practice Address - Street 1:21501 SW 113TH AVE APT 103
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2723
Practice Address - Country:US
Practice Address - Phone:786-499-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-585246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant