MEDICARE: RAUL JARA ATC

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

General Provider Information

NPI Number	:	1700288925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAUL JARA ATC

Provider Business Mailing Address
First Line	:	8453 SW 161ST PL
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-3080
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8453 SW 161ST PL
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33193-3080
Country	:	US
Telephone Number	:	305-904-2549
Fax Number	:

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

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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