MEDICARE: RUBEN DANIEL IBARRA PEREZ

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	106S00000X	Behavior Technician	BACB1350926	FL

General Provider Information

NPI Number	:	1487538476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUBEN DANIEL IBARRA PEREZ

Provider Business Mailing Address
First Line	:	2108 GREENBRIER VILLAGE PASS
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-2244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2108 GREENBRIER VILLAGE PASS
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-2244
Country	:	US
Telephone Number	:	863-378-9733
Fax Number	:

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

Provider Enumeration Date	:	08/02/2025
Last Update Date	:	08/02/2025

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