Healthcare Provider Details

I. General information

NPI: 1659554798
Provider Name (Legal Business Name): EVARISTO E. RIVERO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E INTERLAKE BLVD
LAKE PLACID FL
33852-9603
US

IV. Provider business mailing address

230 E INTERLAKE BLVD
LAKE PLACID FL
33852-9603
US

V. Phone/Fax

Practice location:
  • Phone: 863-699-6001
  • Fax: 863-699-6002
Mailing address:
  • Phone: 863-699-6001
  • Fax: 863-699-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2506
License Number StateFL

VIII. Authorized Official

Name: DR. EVARISTO E. RIVERO
Title or Position: OWNER
Credential: DPM
Phone: 863-699-6001