Provider Demographics
NPI:1467900670
Name:RIVERA, LUIS ALBERTO JR (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ALBERTO
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11216 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3556
Mailing Address - Country:US
Mailing Address - Phone:305-484-5619
Mailing Address - Fax:
Practice Address - Street 1:1701 NE 127TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-2518
Practice Address - Country:US
Practice Address - Phone:305-892-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 44412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL 4441OtherFLORIDA ATHLETIC TRAINING LICENSE
FL2000023050OtherBOC CERTIFICATION