Healthcare Provider Details

I. General information

NPI: 1053967521
Provider Name (Legal Business Name): MIA ARIEL RIVARDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR STE LL105
PLAINVIEW NY
11803-1718
US

IV. Provider business mailing address

511 DECATUR ST APT 2
BROOKLYN NY
11233-1502
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-0962
  • Fax:
Mailing address:
  • Phone: 504-432-4069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: