MEDICARE: LAURA STEPHANIE CUBILLOS ATC, LAT

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	2255A2300X	Athletic Trainer	4450	FL

General Provider Information

NPI Number	:	1649792870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA STEPHANIE CUBILLOS ATC, LAT

Provider Business Mailing Address
First Line	:	1250 E HALLANDALE BEACH BLVD STE 700
Second Line	:
City	:	HALLANDALE BEACH
State	:	FL
Zip	:	33009-4641
Country	:	US
Telephone Number	:	954-456-6080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E HALLANDALE BEACH BLVD STE 700
Second Line	:
City	:	HALLANDALE BEACH
State	:	FL
Zip	:	33009-4641
Country	:	US
Telephone Number	:	954-456-6080
Fax Number	:

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

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	07/21/2022

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