1124630892 NPI number — MOSELENE BELIZAIRE SOLE PROPRIETOR

Table of content: MOSELENE BELIZAIRE SOLE PROPRIETOR (NPI 1124630892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124630892 NPI number — MOSELENE BELIZAIRE SOLE PROPRIETOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BELIZAIRE
Provider First Name:
MOSELENE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SOLE PROPRIETOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124630892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3411 9TH ST W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHIGH ACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33971-5357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-258-6862
Provider Business Mailing Address Fax Number:
239-362-1561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3411 9TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33971-5357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-258-6862
Provider Business Practice Location Address Fax Number:
239-362-1561
Provider Enumeration Date:
08/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311ZA0620X , with the licence number: 6907016 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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