Healthcare Provider Details

I. General information

NPI: 1558597005
Provider Name (Legal Business Name): LICE CLEANIQUE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 W ATLANTIC AVE SUITE 400-A
DELRAY BEACH FL
33484-8102
US

IV. Provider business mailing address

6971 W SUNRISE BLVD SUITE 102
PLANTATION FL
33313-4407
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-0166
  • Fax: 561-381-4581
Mailing address:
  • Phone: 954-791-0711
  • Fax: 954-791-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberHCC8590
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberHCC8590
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberHCC8590
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberHCC8590
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License NumberHCC8590
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberHCC8590
License Number StateFL

VIII. Authorized Official

Name: MRS. LIDIA E SERRANO
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 954-791-0711