MEDICARE: JUAN CARLOS IBARRA MORENO SA-C

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	246ZC0007X	Surgical Assistant	13-514	FL

General Provider Information

NPI Number	:	1780126219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN CARLOS IBARRA MORENO SA-C

Provider Business Mailing Address
First Line	:	6150 DIAMOND CENTRE CT # 1300
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4367
Country	:	US
Telephone Number	:	239-344-9786
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 DIAMOND CENTRE CT UNIT 1200
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-7135
Country	:	US
Telephone Number	:	239-344-9786
Fax Number	:	239-344-9215

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

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	04/10/2020

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