Healthcare Provider Details

I. General information

NPI: 1649881434
Provider Name (Legal Business Name): DR JOSE A RIVERA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 A1A N STE 310
PONTE VEDRA BEACH FL
32082-8209
US

IV. Provider business mailing address

PO BOX 8209
VIENNA VA
22183-2058
US

V. Phone/Fax

Practice location:
  • Phone: 251-901-3011
  • Fax:
Mailing address:
  • Phone: 251-901-3011
  • Fax: 833-469-6349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSE ARNALDO RIVERA
Title or Position: PRESIDENT
Credential: DPM
Phone: 251-901-3011