Provider Demographics
NPI:1114414380
Name:RIVERA, JOSE A (MANAGING CONTROL CEO)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MANAGING CONTROL CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 N JOHN YOUNG PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741
Mailing Address - Country:US
Mailing Address - Phone:407-994-4606
Mailing Address - Fax:888-338-4430
Practice Address - Street 1:1906 N JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-994-4606
Practice Address - Fax:888-338-4430
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care