MEDICARE: MRS. DANYETTA TAVARES 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	172V00000X	Community Health Worker		FL

General Provider Information

NPI Number	:	1942681275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANYETTA TAVARES OWNER

Provider Business Mailing Address
First Line	:	1433 FONTAINE DR
Second Line	:
City	:	APOPKA
State	:	FL
Zip	:	32703-7337
Country	:	US
Telephone Number	:	407-242-0210
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 PICCADILLY DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-3829
Country	:	US
Telephone Number	:	407-242-0210
Fax Number	:

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

Provider Enumeration Date	:	06/11/2015
Last Update Date	:	06/11/2015

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