Healthcare Provider Details

I. General information

NPI: 1619702578
Provider Name (Legal Business Name): YANDRY GUTIERREZ RIVERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4793 N CONGRESS AVE STE 203-204
BOYNTON BEACH FL
33426-7937
US

IV. Provider business mailing address

441 BROWARD AVE
GREENACRES FL
33463-2001
US

V. Phone/Fax

Practice location:
  • Phone: 561-429-3863
  • Fax:
Mailing address:
  • Phone: 561-654-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1149377
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: