Healthcare Provider Details

I. General information

NPI: 1982115093
Provider Name (Legal Business Name): ROSANA THEOPHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4561 NW 10TH AVE
FORT LAUDERDALE FL
33309-3869
US

IV. Provider business mailing address

4561 NW 10TH AVE
FORT LAUDERDALE FL
33309-3869
US

V. Phone/Fax

Practice location:
  • Phone: 954-683-7155
  • Fax:
Mailing address:
  • Phone: 954-683-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906874
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: