Provider Demographics
NPI:1386292936
Name:RIVERA COLON, ILIANNETTE (DC)
Entity type:Individual
Prefix:
First Name:ILIANNETTE
Middle Name:
Last Name:RIVERA COLON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 HELENA ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4355
Mailing Address - Country:US
Mailing Address - Phone:727-226-0583
Mailing Address - Fax:
Practice Address - Street 1:6220 MANATEE AVE W STE 204
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2361
Practice Address - Country:US
Practice Address - Phone:941-761-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor