MEDICARE: JESUS CAROLLO MACHADO

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	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1679189948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESUS CAROLLO MACHADO

Provider Business Mailing Address
First Line	:	6312 ROYAL HUNT DR APT 203
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33625-2533
Country	:	US
Telephone Number	:	813-562-5104
Fax Number	:

Provider Business Practice Location Address
First Line	:	6312 ROYAL HUNT DR APT 203
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33625-2533
Country	:	US
Telephone Number	:	813-562-5104
Fax Number	:

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

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	09/21/2020

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Directions to “ JESUS CAROLLO MACHADO ” Practice Location

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