Healthcare Provider Details

I. General information

NPI: 1629524640
Provider Name (Legal Business Name): MARIA INMACULADA CUERVO Y BENNETT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAMINO SANTA MARIA ST ATHLETIC TRAINING DEPARTMENT
SAN ANTONIO TX
78228-5433
US

IV. Provider business mailing address

4207 ROLLING OAK DR
LAKELAND FL
33810-1286
US

V. Phone/Fax

Practice location:
  • Phone: 210-431-5043
  • Fax:
Mailing address:
  • Phone: 863-255-9953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: