MEDICARE: GUILLOT ENTERPRISES, LLC

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	261QH0700X	Hearing and Speech Clinic/Center	AS4869	FL

General Provider Information

NPI Number	:	1174950083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUILLOT ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	4130 NW 37TH PL
Second Line	:	SUITE C
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-8152
Country	:	US
Telephone Number	:	352-377-4111
Fax Number	:	352-367-1453

Provider Business Practice Location Address
First Line	:	1107 S WALNUT ST
Second Line	:
City	:	STARKE
State	:	FL
Zip	:	32091-4413
Country	:	US
Telephone Number	:	904-964-4327
Fax Number	:	904-368-0574

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. TOM GUILLOT
Credential	:	BC-HIS
Telephone Number	:	352-377-4111

Provider Enumeration Date	:	10/09/2013
Last Update Date	:	10/09/2013

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