MEDICARE: TAMARA D EDWARDS-CRUZ BUSINESS OWNER

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	172A00000X	Driver	E363804748750	FL

General Provider Information

NPI Number	:	1881377752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA D EDWARDS-CRUZ BUSINESS OWNER

Provider Business Mailing Address
First Line	:	6001 ARGYLE FOREST BLVD
Second Line	:	STE21 #153
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244
Country	:	US
Telephone Number	:	904-861-6686
Fax Number	:

Provider Business Practice Location Address
First Line	:	2489 W 30TH ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3407
Country	:	US
Telephone Number	:	904-607-6124
Fax Number	:

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

Provider Enumeration Date	:	08/08/2023
Last Update Date	:	08/08/2023

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