MEDICARE: FARRELL EUGENE JACKSON

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	227900000X	Registered Respiratory Therapist	RT10376	FL

General Provider Information

NPI Number	:	1023320694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FARRELL EUGENE JACKSON

Provider Business Mailing Address
First Line	:	850 NW 172ND TER
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-5305
Country	:	US
Telephone Number	:	305-620-3533
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 NW 172ND TER
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-5305
Country	:	US
Telephone Number	:	305-620-3533
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2010
Last Update Date	:	07/11/2010

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