MEDICARE: MR. JOSE PEREZ RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	299993849	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10-9785	OTHER	FL	PTAN

General Provider Information

NPI Number	:	1053739169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE PEREZ RN

Provider Business Mailing Address
First Line	:	11814 N 56TH ST STE A
Second Line	:
City	:	TEMPLE TERRACE
State	:	FL
Zip	:	33617-1698
Country	:	US
Telephone Number	:	813-642-9000
Fax Number	:	813-642-9001

Provider Business Practice Location Address
First Line	:	11814 N 56TH ST STE A
Second Line	:
City	:	TEMPLE TERRACE
State	:	FL
Zip	:	33617-1698
Country	:	US
Telephone Number	:	813-642-9000
Fax Number	:	813-642-9001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2014
Last Update Date	:	05/05/2014

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Directions to “ MR. JOSE PEREZ RN” Practice Location

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