Basic Information
| Provider Information | |||||||||
| NPI: | 1619300654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALAVE | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | RAEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | ATC, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERA ROMAN | ||||||||
| OtherFirstName: | VIVIAN | ||||||||
| OtherMiddleName: | RAEL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6416 OLD WINTER GARDEN RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328351348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077517288 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 14075 TOWN LOOP BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328376132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074385858 | ||||||||
| FaxNumber: | 4074387172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 3559 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | PA9111563 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.