Provider Demographics
NPI:1891172466
Name:RIVERA, VIVIAN NIDZA (LAP # 3539)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:NIDZA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:LAP # 3539
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27908 BRISTOL BAY PL
Mailing Address - Street 2:#104
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8811
Mailing Address - Country:US
Mailing Address - Phone:786-942-5089
Mailing Address - Fax:
Practice Address - Street 1:27908 BRISTOL BAY PL APT 104
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-8813
Practice Address - Country:US
Practice Address - Phone:786-942-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-02
Last Update Date:2015-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3539171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist