MEDICARE: RIVERGATE FAMILY RESOURCE CENTER, LLC.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1982102646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERGATE FAMILY RESOURCE CENTER, LLC.

Provider Business Mailing Address
First Line	:	7481 W OAKLAND PARK BLVD STE 308D
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33319-4961
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7481 W OAKLAND PARK BLVD STE 308D
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33319-4961
Country	:	US
Telephone Number	:	754-400-5407
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	KYRIAKI ROBERTS
Credential	:
Telephone Number	:	754-400-5407

Provider Enumeration Date	:	01/29/2018
Last Update Date	:	01/29/2018

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