Provider Demographics
NPI:1053202085
Name:RIVERA, ODALIS
Entity type:Individual
Prefix:
First Name:ODALIS
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 BLUE JAY DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8835
Mailing Address - Country:US
Mailing Address - Phone:787-292-0892
Mailing Address - Fax:
Practice Address - Street 1:5726 OLD CHENEY HWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3525
Practice Address - Country:US
Practice Address - Phone:407-900-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBHCM.0107683-P171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator