=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376910588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARTHA RIVERA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2015
-----------------------------------------------------
Last Update Date | 08/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6257 SW 150TH PATH
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-543-7677
-----------------------------------------------------
Fax | 305-482-6359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6257 SW 150TH PATH
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-543-7677
-----------------------------------------------------
Fax | 305-482-6359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. MARTHA RIVERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-543-7677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 229690
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------