Healthcare Provider Details

I. General information

NPI: 1124328885
Provider Name (Legal Business Name): IDA RIVERA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SPARTAN DR
MAITLAND FL
32751-3468
US

IV. Provider business mailing address

8215 SARNOW DR
ORLANDO FL
32822-7531
US

V. Phone/Fax

Practice location:
  • Phone: 407-331-8002
  • Fax: 407-261-0523
Mailing address:
  • Phone: 407-921-0669
  • Fax: 407-261-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: