Healthcare Provider Details

I. General information

NPI: 1619189198
Provider Name (Legal Business Name): JOSEPH LIONEL RIVAS SR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

7925 GULF RD S
JACKSONVILLE FL
32244-2524
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-3441
  • Fax:
Mailing address:
  • Phone: 904-771-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: