MEDICARE: SUN CITY SPEECH THERAPY, 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	235Z00000X	Speech-Language Pathologist	111473	TX

General Provider Information

NPI Number	:	1851830756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN CITY SPEECH THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 137
Second Line	:
City	:	SAN ELIZARIO
State	:	TX
Zip	:	79849-0137
Country	:	US
Telephone Number	:	915-820-2889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 TULA COURT
Second Line	:
City	:	SAN ELIZARIO
State	:	TX
Zip	:	79849
Country	:	US
Telephone Number	:	915-820-2889
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/ OWNER
Name	:	JESSICA CANO
Credential	:	M.A., CCC-SLP
Telephone Number	:	915-820-2889

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	02/13/2017

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Directions to “SUN CITY SPEECH THERAPY, LLC ” Practice Location

Language	Start Address	Practice Location

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