Healthcare Provider Details

I. General information

NPI: 1558730085
Provider Name (Legal Business Name): CARTE BLANCHE HOLDINGS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13546 BEACH BLVD UNIT 2
JACKSONVILLE FL
32224-7232
US

IV. Provider business mailing address

1626 N LIBERTY ST
JACKSONVILLE FL
32206-4649
US

V. Phone/Fax

Practice location:
  • Phone: 904-574-5000
  • Fax:
Mailing address:
  • Phone: 904-625-0038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberME42368
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VB0002X
TaxonomyObesity Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BLAKE A KOZOL
Title or Position: PRESIDENT
Credential:
Phone: 904-625-0038