Healthcare Provider Details

I. General information

NPI: 1154167161
Provider Name (Legal Business Name): MARCO ANTONIO RIVERA SOTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8660 W FLAGLER ST STE 121
MIAMI FL
33144-2035
US

IV. Provider business mailing address

6995 NW 173RD DR APT 2105
HIALEAH FL
33015-4023
US

V. Phone/Fax

Practice location:
  • Phone: 305-600-4774
  • Fax:
Mailing address:
  • Phone: 629-800-4652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-359888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: