=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427870476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERIBERTO RIVERA MSOM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11251 S ORANGE BLOSSOM TRL STE 101
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-9297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-501-6841
-----------------------------------------------------
Fax | 407-542-2243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11251 S ORANGE BLOSSOM TRL STE 101
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-9297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-501-6841
-----------------------------------------------------
Fax | 407-542-2243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------