Basic Information
| Provider Information | |||||||||
| NPI: | 1306118716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIOS | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DR.OT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11825 SW 99TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331764111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7869851619 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4545 SW 104TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331655634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052210284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2012 | ||||||||
| LastUpdateDate: | 01/31/2012 | ||||||||
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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 | 174400000X | OT 10519 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 887774200 | 05 | FL | MEDICAID |