Healthcare Provider Details

I. General information

NPI: 1609791706
Provider Name (Legal Business Name): VIDACARE NURSE REGISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 N KILLIAN DR STE 113A
LAKE PARK FL
33403-1960
US

IV. Provider business mailing address

1408 N KILLIAN DR STE 113A
LAKE PARK FL
33403-1960
US

V. Phone/Fax

Practice location:
  • Phone: 561-958-0179
  • Fax: 561-834-3190
Mailing address:
  • Phone: 561-958-0179
  • Fax: 561-834-3190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: GISELLE MORALES LEYVA
Title or Position: OWNER
Credential:
Phone: 561-958-0179