MEDICARE: MR. CHARLES VIRGIL MARTIGNONI III

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	332B00000X	Durable Medical Equipment & Medical Supplies		FL

General Provider Information

NPI Number	:	1255654190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES VIRGIL MARTIGNONI III

Provider Business Mailing Address
First Line	:	3410 GALT OCEAN DR
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-7044
Country	:	US
Telephone Number	:	954-294-4554
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 GALT OCEAN DR
Second Line	:	PH2
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-7044
Country	:	US
Telephone Number	:	954-294-4554
Fax Number	:

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

Provider Enumeration Date	:	03/06/2010
Last Update Date	:	03/06/2010

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