Healthcare Provider Details

I. General information

NPI: 1275086357
Provider Name (Legal Business Name): FAIR BREEZE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5146 SW 90TH AVE
COOPER CITY FL
33328-3625
US

IV. Provider business mailing address

5146 SW 90TH AVE
COOPER CITY FL
33328-3625
US

V. Phone/Fax

Practice location:
  • Phone: 954-680-7846
  • Fax:
Mailing address:
  • Phone: 954-680-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberW452501626361
License Number StateFL

VIII. Authorized Official

Name: MRS. KARIE ANNETTE WILLIAMS SOTO
Title or Position: OWNER/MANAGER
Credential: CSA
Phone: 954-680-7846