MEDICARE: ROBERTO VEGA

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	RBT-18-68387

General Provider Information

NPI Number	:	1558838920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTO VEGA

Provider Business Mailing Address
First Line	:	10175 FORTUNE PKWY UNIT 903
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6755
Country	:	US
Telephone Number	:	904-538-0713
Fax Number	:

Provider Business Practice Location Address
First Line	:	365 W 1550 N STE F
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-2279
Country	:	US
Telephone Number	:	801-876-5809
Fax Number	:

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

Provider Enumeration Date	:	10/24/2018
Last Update Date	:	10/24/2018

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Directions to “ ROBERTO VEGA ” Practice Location

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