MEDICARE: LUZ MEDY LEBRON MONCLOVA 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	376G00000X	Nursing Home Administrator	RN9227949	FL

General Provider Information

NPI Number	:	1578915070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUZ MEDY LEBRON MONCLOVA RN

Provider Business Mailing Address
First Line	:	5681 EDENFIELD RD
Second Line	:	APT. 1005
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-1469
Country	:	US
Telephone Number	:	904-314-9156
Fax Number	:

Provider Business Practice Location Address
First Line	:	5681 EDENFIELD RD
Second Line	:	APT. 1005
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-1469
Country	:	US
Telephone Number	:	904-314-9156
Fax Number	:

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

Provider Enumeration Date	:	07/07/2016
Last Update Date	:	07/07/2016

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