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NPI Code Detail

MEDICARE: MISS IRELIAM GUADALUPE MS, LAT, ATC

MEDICARE: MISS IRELIAM GUADALUPE MS, LAT, 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
12255A2300XAthletic TrainerAL2555FL

General Provider Information

NPI Number : 1821266644
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS IRELIAM GUADALUPE MS, LAT, ATC
Provider Business Mailing Address
First Line : 12801 EAGLE POINTE CIR
Second Line :
City : FORT MYERS
State : FL
Zip : 33913-7964
Country : US
Telephone Number : 239-340-9111
Fax Number :
Provider Business Practice Location Address
First Line : 10501 FGCU BLVD S
Second Line :
City : FORT MYERS
State : FL
Zip : 33965-5588
Country : US
Telephone Number : 239-745-4299
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/14/2008
Last Update Date : 11/21/2019

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