MEDICARE: MS. CAMERA AQUILA QUEBEC

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1750570222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAMERA AQUILA QUEBEC

Provider Business Mailing Address
First Line	:	182 GRAND ST FL 4
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06702-1914
Country	:	US
Telephone Number	:	203-437-7079
Fax Number	:

Provider Business Practice Location Address
First Line	:	182 GRAND ST FL 4
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06702-1914
Country	:	US
Telephone Number	:	203-437-7079
Fax Number	:	203-439-0044

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

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	06/30/2014

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