MEDICARE: TRIPLE - I - CARE 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1922237007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIPLE - I - CARE LLC

Provider Business Mailing Address
First Line	:	5210 WEBB RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-4518
Country	:	US
Telephone Number	:	813-882-9986
Fax Number	:	813-884-5616

Provider Business Practice Location Address
First Line	:	5535 MEMORIAL HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-7370
Country	:	US
Telephone Number	:	813-374-9172
Fax Number	:	813-374-9174

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PANOS VASILOUDES
Credential	:	MD
Telephone Number	:	813-882-9986

Provider Enumeration Date	:	07/09/2009
Last Update Date	:	02/17/2010

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