Organization
RIVIERA PLAZA MEDICAL OFFICE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GLORIA HELEN MIKULA MD (MEDICAL DIRECTOR)
(386) 677-5415
Entity
Organization
Contact information
Practice address
1702 RIDGEWOOD AVE, SUITE I, HOLLY HILL, FL 32117-5416
(386) 677-5415
(386) 677-1475
Mailing address
208 N HALIFAX AVE, SUITE1, DAYTONA BEACH, FL 32118-4159
(386) 677-5415
(386) 677-1475
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
ME47765
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
042193600
—
FL
01
—
HS776A
MEDICARE PTAN
FL
Enumeration date
12/16/2013
Last updated
04/23/2014
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