MEDICARE: MRS. GUSTAVO CEPERO

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	225700000X	Massage Therapist	MA66643	FL

General Provider Information

NPI Number	:	1033480496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GUSTAVO CEPERO

Provider Business Mailing Address
First Line	:	17240 S TAMIAMI TRL
Second Line	:	SUITE#6
City	:	FORT MYERS
State	:	FL
Zip	:	33908-4574
Country	:	US
Telephone Number	:	239-603-6836
Fax Number	:	786-752-3280

Provider Business Practice Location Address
First Line	:	8477 CORAL DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-2641
Country	:	US
Telephone Number	:	239-603-6836
Fax Number	:	786-752-3280

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

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/24/2012

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