MEDICARE: BOYETTE SPINE AND JOINT CENTER 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	174400000X	Specialist

General Provider Information

NPI Number	:	1427478957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOYETTE SPINE AND JOINT CENTER LLC

Provider Business Mailing Address
First Line	:	10833 BOYETTE RD
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8012
Country	:	US
Telephone Number	:	813-741-1835
Fax Number	:	813-741-0945

Provider Business Practice Location Address
First Line	:	10833 BOYETTE RD
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8012
Country	:	US
Telephone Number	:	813-741-1835
Fax Number	:	813-741-0945

Authorized Official
Title or Position	:	OFFICE MNGR
Name	:	KATHY JARVIS
Credential	:
Telephone Number	:	813-741-1835

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	09/10/2014

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