MEDICARE: BUENA SUERTE, INC.

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	347C00000X	Private Vehicle		AZ
2	253Z00000X	In Home Supportive Care Agency		AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003128349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA SUERTE, INC.

Provider Business Mailing Address
First Line	:	387 LAKE HAVASU AVE S
Second Line	:	SUITE 102
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9306
Country	:	US
Telephone Number	:	928-855-0005
Fax Number	:	928-855-0075

Provider Business Practice Location Address
First Line	:	387 LAKE HAVASU AVE S
Second Line	:	SUITE 102
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-9306
Country	:	US
Telephone Number	:	928-855-0005
Fax Number	:	928-855-0075

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHRISTOPHER L GAMBLE
Credential	:
Telephone Number	:	301-639-3822

Provider Enumeration Date	:	07/01/2010
Last Update Date	:	04/30/2011

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Directions to “BUENA SUERTE, INC. ” Practice Location

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