Healthcare Provider Details

I. General information

NPI: 1356162952
Provider Name (Legal Business Name): THE BLUE TREE CAFE LIMITED LIABILITY CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 NW 9TH AVE STE A
FT LAUDERDALE FL
33311-7674
US

IV. Provider business mailing address

2701 TARPON DR
MIRAMAR FL
33023-4524
US

V. Phone/Fax

Practice location:
  • Phone: 786-239-9131
  • Fax:
Mailing address:
  • Phone: 786-239-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State

VIII. Authorized Official

Name: SHARON ALLEN
Title or Position: OWNER
Credential: MS.
Phone: 786-239-9131