MEDICARE: ATLANTIC COAST PHLEBOTOMY INSTRUCTION LLC

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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1730772823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC COAST PHLEBOTOMY INSTRUCTION LLC

Provider Business Mailing Address
First Line	:	814 COCHRAN DR
Second Line	:
City	:	LAKE WORTH BEACH
State	:	FL
Zip	:	33461-5709
Country	:	US
Telephone Number	:	156-192-9137
Fax Number	:

Provider Business Practice Location Address
First Line	:	814 COCHRAN DR
Second Line	:
City	:	LAKE WORTH BEACH
State	:	FL
Zip	:	33461-5709
Country	:	US
Telephone Number	:	561-929-1373
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. TAMMY MARIE CAROLLO
Credential	:	PHLEBOTOMIST
Telephone Number	:	561-929-1373

Provider Enumeration Date	:	02/19/2021
Last Update Date	:	02/19/2021

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