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General NPI Number Information
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NPI Number | 1013338144
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Entity Type | Organization
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Legal Business Name | RIVIERA PLAZA MEDICAL OFFICE LLC
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Dates
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Enumeration Date | 12/16/2013
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Last Update Date | 04/23/2014
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Provider Practice Location Address
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Address Line | 1702 RIDGEWOOD AVE SUITE I
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City | HOLLY HILL
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State | FL
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Zip | 32117-5416
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Country | US
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Telephone | 386-677-5415
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Fax | 386-677-1475
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Provider Business Mailing Address
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Address Line | 208 N HALIFAX AVE SUITE1
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City | DAYTONA BEACH
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State | FL
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Zip | 32118-4159
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Country | US
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Telephone | 386-677-5415
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Fax | 386-677-1475
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. GLORIA HELEN MIKULA
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Credential | MD
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Telephone | 386-677-5415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME47765
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License Number State | FL
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