Provider Demographics
NPI:1811136773
Name:INDIAN RIVER INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:INDIAN RIVER INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ENIO
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-581-1881
Mailing Address - Street 1:7935 BAY ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3282
Mailing Address - Country:US
Mailing Address - Phone:772-581-1881
Mailing Address - Fax:772-581-1885
Practice Address - Street 1:7935 BAY ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3282
Practice Address - Country:US
Practice Address - Phone:772-581-1881
Practice Address - Fax:772-581-1885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty