=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588462758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL AVILES CSFA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7171 N DALE MABRY HWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-932-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11506 ECHO LAKE CIR UNIT 305
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-705-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 209101
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------