Provider Demographics
NPI:1417209511
Name:ELOMINA, IRES GALLO
Entity Type:Individual
Prefix:
First Name:IRES
Middle Name:GALLO
Last Name:ELOMINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRIS
Other - Middle Name:G
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:718 GARDEN PLAZA
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1111
Mailing Address - Country:US
Mailing Address - Phone:407-488-3557
Mailing Address - Fax:407-894-8893
Practice Address - Street 1:718 GARDEN PLAZA
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1111
Practice Address - Country:US
Practice Address - Phone:407-488-3557
Practice Address - Fax:407-894-8893
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator