Healthcare Provider Details

I. General information

NPI: 1033024880
Provider Name (Legal Business Name): CHARLES G. RIVERA-MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12018 STREAMBED DR
RIVERVIEW FL
33579-9318
US

IV. Provider business mailing address

12018 STREAMBED DR
RIVERVIEW FL
33579-9318
US

V. Phone/Fax

Practice location:
  • Phone: 813-424-8896
  • Fax:
Mailing address:
  • Phone: 813-424-8896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: