Healthcare Provider Details

I. General information

NPI: 1972887164
Provider Name (Legal Business Name): CAROLINE GOSSAGE FAXAS A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 NE 2ND AVE
DELRAY BEACH FL
33444-3703
US

IV. Provider business mailing address

3336 OLD OAK LN
HOLLYWOOD FL
33021-8438
US

V. Phone/Fax

Practice location:
  • Phone: 561-455-2147
  • Fax: 561-455-2762
Mailing address:
  • Phone: 954-243-9093
  • Fax: 954-333-3556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 3023
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: