=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336502962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULLIAM RIVERA DPT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2016
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9975 TAVISTOCK LAKES BLVD STE 140
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32827-7665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-373-9910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14106 RED ROBIN CT
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32824-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-276-1255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL4435
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------