MEDICARE: MR. SANTIAGO J RIVERA PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	PTA11718	FL

General Provider Information

NPI Number	:	1174741615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SANTIAGO J RIVERA PTA

Provider Business Mailing Address
First Line	:	3420 NW 112TH TER
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-7094
Country	:	US
Telephone Number	:	954-345-5117
Fax Number	:	954-345-5459

Provider Business Practice Location Address
First Line	:	3420 NW 112TH TER
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-7094
Country	:	US
Telephone Number	:	954-345-5117
Fax Number	:	954-345-5459

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	07/08/2007

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