Healthcare Provider Details

I. General information

NPI: 1003621103
Provider Name (Legal Business Name): ANDREW RIVERA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 S FLORIDA AVE STE 107
LAKELAND FL
33813-1150
US

IV. Provider business mailing address

3900 S FLORIDA AVE STE 107
LAKELAND FL
33813-1150
US

V. Phone/Fax

Practice location:
  • Phone: 863-647-3665
  • Fax:
Mailing address:
  • Phone: 863-647-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT45019
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: