MEDICARE: MR. LUIS ALBERTO RIVERA JR. LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL 4441	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AL 4441	OTHER	FL	FLORIDA ATHLETIC TRAINING LICENSE
2	2000023050	OTHER	FL	BOC CERTIFICATION

General Provider Information

NPI Number	:	1467900670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LUIS ALBERTO RIVERA JR. LAT, ATC

Provider Business Mailing Address
First Line	:	11216 NW 6TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33172-3556
Country	:	US
Telephone Number	:	305-484-5619
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 NE 127TH ST
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2518
Country	:	US
Telephone Number	:	305-892-7631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2016
Last Update Date	:	09/16/2016

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