Healthcare Provider Details

I. General information

NPI: 1891358651
Provider Name (Legal Business Name): ROSA IRIS RIVERA DBA,MLS (ASCP)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4068-1 FOREST HILL BLVD
WEST PALM BEACH FL
33406
US

IV. Provider business mailing address

1053 SW12TH ST
BOCA RATON FL
33486
US

V. Phone/Fax

Practice location:
  • Phone: 561-386-7182
  • Fax:
Mailing address:
  • Phone: 561-386-7182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number26988979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: