Basic Information
| Provider Information | |||||||||
| NPI: | 1205445269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADRON RIVERO | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | LADYES | ||||||||
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| Credential: | BACB572667 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4802 CYPRESS RIDGE PL | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336246308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862901528 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3309 W WATERS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336142766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138980014 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2020 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-127932 | FL | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | BACB572667 | 05 | FL | MEDICAID |