MEDICARE: REBECCA SOPHIA GUILLEN ATC, LAT

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	2255A2300X	Athletic Trainer	AL2855	FL

General Provider Information

NPI Number	:	1144770397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA SOPHIA GUILLEN ATC, LAT

Provider Business Mailing Address
First Line	:	2901 BUSCH LAKE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1860
Country	:	US
Telephone Number	:	813-936-7979
Fax Number	:	813-936-1600

Provider Business Practice Location Address
First Line	:	2901 BUSCH LAKE BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1860
Country	:	US
Telephone Number	:	813-936-7979
Fax Number	:	813-936-1600

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

Provider Enumeration Date	:	10/12/2016
Last Update Date	:	10/12/2016

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