MEDICARE: DESLY JESUS RUIZ AMORES SA-C

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	246ZC0007X	Surgical Assistant	19-186	WI

General Provider Information

NPI Number	:	1760945844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESLY JESUS RUIZ AMORES SA-C

Provider Business Mailing Address
First Line	:	1922 HIBISCUS LN
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-1873
Country	:	US
Telephone Number	:	561-412-9349
Fax Number	:

Provider Business Practice Location Address
First Line	:	1922 HIBISCUS LN
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-1873
Country	:	US
Telephone Number	:	561-412-9349
Fax Number	:

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

Provider Enumeration Date	:	04/07/2019
Last Update Date	:	04/07/2019

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