MEDICARE: THERAPY CENTER OF TAMPA LLC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1043671852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPY CENTER OF TAMPA LLC

Provider Business Mailing Address
First Line	:	3434 W COLUMBUS DR
Second Line	:	SUITE 106
City	:	TAMPA
State	:	FL
Zip	:	33607-1860
Country	:	US
Telephone Number	:	813-252-8446
Fax Number	:	813-252-8453

Provider Business Practice Location Address
First Line	:	3434 W COLUMBUS DR
Second Line	:	SUITE 106
City	:	TAMPA
State	:	FL
Zip	:	33607-1860
Country	:	US
Telephone Number	:	813-252-8446
Fax Number	:	813-252-8453

Authorized Official
Title or Position	:	OWNER
Name	:	IVETTE ULLOA
Credential	:
Telephone Number	:	81332528446

Provider Enumeration Date	:	03/08/2016
Last Update Date	:	02/22/2017

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