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General NPI Number Information
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NPI Number | 1689945586
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Entity Type | Individual
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Provider Name | JONATHAN RIVERA PTA
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Gender | Male
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Dates
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Enumeration Date | 01/24/2012
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Last Update Date | 01/24/2012
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Provider Practice Location Address
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Address Line | 30125 BARNABY LN
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543-3702
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Country | US
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Telephone | 813-997-4118
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Fax | 813-994-4118
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Provider Business Mailing Address
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Address Line | 30125 BARNABY LN
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City | WESLEY CHAPEL
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State | FL
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Zip | 33543-3702
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Country | US
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Telephone | 813-997-4118
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Fax | 813-994-4118
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 260407362
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License Number State | FL
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