Basic Information
| Provider Information | |||||||||
| NPI: | 1164496972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | AIDA | ||||||||
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| NamePrefix: | MS. | ||||||||
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| Credential: | MSPT, ATC , LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2455 TESORO CT | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347443924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074147332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 W BASS ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347415011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078705959 | ||||||||
| FaxNumber: | 4079336468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT22425 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | AL 1979 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.