| Riviera Plaza Medical Office Llc | |
|
1702 Ridgewood Ave Suite I Holly Hill FL 32117-5416 | |
| (386) 677-5415 | |
| (386) 677-1475 |
| Full Name | Riviera Plaza Medical Office Llc |
|---|---|
| Speciality | Clinic/center - Primary Care |
| Location | 1702 Ridgewood Ave, Holly Hill, Florida |
| Authorized Official Name and Position | Gloria Helen Mikula (MEDICAL DIRECTOR) |
| Authorized Official Contact | 3866775415 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Riviera Plaza Medical Office Llc 208 N Halifax Ave Suite1 Daytona Beach FL 32118-4159 Ph: (386) 677-5415 | Riviera Plaza Medical Office Llc 1702 Ridgewood Ave Suite I Holly Hill FL 32117-5416 Ph: (386) 677-5415 |
| NPI Number | 1013338144 |
|---|---|
| Provider Enumeration Date | 12/16/2013 |
| Last Update Date | 04/23/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013338144 | NPI | - | NPPES |
| 042193600 | Medicaid | FL | |
| HS776A | Other | FL | MEDICARE PTAN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | ME47765 (Florida) | Primary |
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