Provider Demographics
NPI:1568862449
Name:RIVERA, RICARDO III (BS)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:RIVERA
Suffix:III
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12679 ENCLAVE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6203
Mailing Address - Country:US
Mailing Address - Phone:321-443-7191
Mailing Address - Fax:
Practice Address - Street 1:801 DOUGLAS AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-5206
Practice Address - Country:US
Practice Address - Phone:321-443-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator