Provider Demographics
NPI:1285473355
Name:RIASCOS RAMOS, JUAN FERNANDO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:FERNANDO
Last Name:RIASCOS RAMOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 SW LIGORIO WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-6315
Mailing Address - Country:US
Mailing Address - Phone:954-937-1454
Mailing Address - Fax:
Practice Address - Street 1:1600 SW SYLVESTER LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-3605
Practice Address - Country:US
Practice Address - Phone:772-333-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-348221106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician