MEDICARE: BACALLAO HEALTH SERVIES,CORP

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	207W00000X	Ophthalmology Physician	ME 92076	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710118492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACALLAO HEALTH SERVIES,CORP

Provider Business Mailing Address
First Line	:	7601 E TREASURE DR
Second Line	:	SUITE 1703
City	:	NORTH BAY VILLAGE
State	:	FL
Zip	:	33141-4391
Country	:	US
Telephone Number	:	786-200-3217
Fax Number	:

Provider Business Practice Location Address
First Line	:	7601 E TREASURE DR
Second Line	:	SUITE 1703
City	:	NORTH BAY VILLAGE
State	:	FL
Zip	:	33141-4391
Country	:	US
Telephone Number	:	786-200-3217
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JORGE J BACALLAO
Credential	:	M.D
Telephone Number	:	786-200-3217

Provider Enumeration Date	:	07/29/2009
Last Update Date	:	07/29/2009

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