Provider Demographics
NPI:1013338144
Name:RIVIERA PLAZA MEDICAL OFFICE LLC
Entity Type:Organization
Organization Name:RIVIERA PLAZA MEDICAL OFFICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:MIKULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-677-5415
Mailing Address - Street 1:208 N HALIFAX AVE
Mailing Address - Street 2:SUITE1
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4159
Mailing Address - Country:US
Mailing Address - Phone:386-677-5415
Mailing Address - Fax:386-677-1475
Practice Address - Street 1:1702 RIDGEWOOD AVE
Practice Address - Street 2:SUITE I
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-5416
Practice Address - Country:US
Practice Address - Phone:386-677-5415
Practice Address - Fax:386-677-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47765261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL042193600Medicaid
FLHS776AOtherMEDICARE PTAN
FLHS776AOtherMEDICARE PTAN
FL02936Medicare PIN