MEDICARE: CARTE BLANCHE HOLDINGS, INC

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	207RB0002X	Obesity Medicine (Internal Medicine) Physician
2	207VB0002X	Obesity Medicine (Obstetrics & Gynecology) Physician
3	207QB0002X	Obesity Medicine (Family Medicine) Physician	ME42368	FL

General Provider Information

NPI Number	:	1558730085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARTE BLANCHE HOLDINGS, INC

Provider Business Mailing Address
First Line	:	1626 N LIBERTY ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4649
Country	:	US
Telephone Number	:	904-625-0038
Fax Number	:

Provider Business Practice Location Address
First Line	:	13546 BEACH BLVD
Second Line	:	UNIT 2
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-7232
Country	:	US
Telephone Number	:	904-574-5000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BLAKE A KOZOL
Credential	:
Telephone Number	:	904-625-0038

Provider Enumeration Date	:	09/15/2015
Last Update Date	:	09/15/2015

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