Provider Demographics
NPI:1336502962
Name:RIVERA, JULLIAM (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JULLIAM
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14106 RED ROBIN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-6314
Mailing Address - Country:US
Mailing Address - Phone:407-276-1255
Mailing Address - Fax:
Practice Address - Street 1:9975 TAVISTOCK LAKES BLVD STE 140
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7665
Practice Address - Country:US
Practice Address - Phone:407-373-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL44352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer