Healthcare Provider Details

I. General information

NPI: 1164565446
Provider Name (Legal Business Name): LUCILLE BESELER LD RD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 COLONIAL DR SUITE 108
MARGATE FL
33063-5675
US

IV. Provider business mailing address

5901 COLONIAL DR SUITE 108
MARGATE FL
33063-5675
US

V. Phone/Fax

Practice location:
  • Phone: 954-972-2123
  • Fax: 954-972-4567
Mailing address:
  • Phone: 954-972-2123
  • Fax: 954-972-4567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberN2042
License Number StateFL

VIII. Authorized Official

Name: MS. LUCILLE BESELER
Title or Position: OWNER
Credential: RD LD CDE
Phone: 954-972-2123