Healthcare Provider Details

I. General information

NPI: 1942071907
Provider Name (Legal Business Name): JORGE ENRIQUE RIVERA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13195 SW 134TH ST STE 201
MIAMI FL
33186-4585
US

IV. Provider business mailing address

14833 SW 90TH TER
MIAMI FL
33196-1491
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone: 786-209-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-309101
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: