Basic Information
| Provider Information | |||||||||
| NPI: | 1922392786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA RIVA MARCY | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077757654 | ||||||||
| FaxNumber: | 4078346082 | ||||||||
| Practice Location | |||||||||
| Address1: | 5727 CANTON CV | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | WINTER SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327085033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076952020 | ||||||||
| FaxNumber: | 4076995666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT002618 | GA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 007641 | NY | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC4629 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 004538300 | 05 | FL | MEDICAID |