MEDICARE: ADELIS JACINTO VARGAS TORREALBA SA-C

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	246ZC0007X	Surgical Assistant	19-214	FL

General Provider Information

NPI Number	:	1356905111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELIS JACINTO VARGAS TORREALBA SA-C

Provider Business Mailing Address
First Line	:	7941 WEST DR APT 201
Second Line	:
City	:	NORTH BAY VILLAGE
State	:	FL
Zip	:	33141-5589
Country	:	US
Telephone Number	:	980-245-6114
Fax Number	:

Provider Business Practice Location Address
First Line	:	7941 WEST DR APT 201
Second Line	:
City	:	NORTH BAY VILLAGE
State	:	FL
Zip	:	33141-5589
Country	:	US
Telephone Number	:	980-245-6114
Fax Number	:

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

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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