MEDICARE: DR. ANTONIO CARMONA FERNANDO DC

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	111N00000X	Chiropractor	5712L	PA

General Provider Information

NPI Number	:	1275512121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTONIO CARMONA FERNANDO DC

Provider Business Mailing Address
First Line	:	305 2ND AVE
Second Line	:
City	:	COLLEGEVILLE
State	:	PA
Zip	:	19426-2658
Country	:	US
Telephone Number	:	610-831-8086
Fax Number	:	610-831-8087

Provider Business Practice Location Address
First Line	:	305 2ND AVE
Second Line	:
City	:	COLLEGEVILLE
State	:	PA
Zip	:	19426-2658
Country	:	US
Telephone Number	:	610-831-8086
Fax Number	:	610-831-8087

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	07/08/2007

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