Healthcare Provider Details

I. General information

NPI: 1659563971
Provider Name (Legal Business Name): CMS IRRV COMPLEX TRUST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 S COMMERCE AVE
SEBRING FL
33870-3607
US

IV. Provider business mailing address

343 S COMMERCE AVE
SEBRING FL
33870-3607
US

V. Phone/Fax

Practice location:
  • Phone: 863-382-2772
  • Fax: 863-382-3172
Mailing address:
  • Phone: 863-382-2772
  • Fax: 863-382-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME0043253
License Number StateFL

VIII. Authorized Official

Name: DR. CIRILO M SERALDE JR.
Title or Position: DIRECTOR/PHYSICIAN
Credential: M.D.
Phone: 863-382-2772