MEDICARE: EILEEN E FUENTES

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1629613559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EILEEN E FUENTES

Provider Business Mailing Address
First Line	:	12714 MOSS PARK RIDGE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-7086
Country	:	US
Telephone Number	:	407-864-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	12714 MOSS PARK RIDGE DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32832-7086
Country	:	US
Telephone Number	:	407-864-6494
Fax Number	:

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

Provider Enumeration Date	:	11/14/2019
Last Update Date	:	11/14/2019

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Directions to “ EILEEN E FUENTES ” Practice Location

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