MEDICARE: DEPARTMENT OF VETERANS AFFAIR

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	261QM0850X	Adult Mental Health Clinic/Center	SW 9212	FL

General Provider Information

NPI Number	:	1588903850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEPARTMENT OF VETERANS AFFAIR

Provider Business Mailing Address
First Line	:	656 SW SANDBAR TER
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-1951
Country	:	US
Telephone Number	:	772-475-1248
Fax Number	:

Provider Business Practice Location Address
First Line	:	656 SW SANDBAR TER
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-1951
Country	:	US
Telephone Number	:	772-475-1248
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	ALFARIDYS RODRIGUEZ
Credential	:
Telephone Number	:	772-475-1248

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	02/06/2013

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