MEDICARE: MR. SERGIO ROBERTO CEBALLOS LMT

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	247200000X	Other Technician	MA54554	FL

General Provider Information

NPI Number	:	1508016320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SERGIO ROBERTO CEBALLOS LMT

Provider Business Mailing Address
First Line	:	7506 COLONIAL CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-1546
Country	:	US
Telephone Number	:	813-480-5046
Fax Number	:

Provider Business Practice Location Address
First Line	:	6506 N FLORIDA AVE
Second Line	:	STE 101
City	:	TAMPA
State	:	FL
Zip	:	33604-6060
Country	:	US
Telephone Number	:	813-964-6872
Fax Number	:

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

Provider Enumeration Date	:	09/29/2008
Last Update Date	:	09/30/2008

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