Healthcare Provider Details

I. General information

NPI: 1417873340
Provider Name (Legal Business Name): MRS. SOPHIA RUCKER-GEFFRARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 NW 200TH TER
MIAMI GARDENS FL
33056-1786
US

IV. Provider business mailing address

3490 NW 200TH TER
MIAMI GARDENS FL
33056-1786
US

V. Phone/Fax

Practice location:
  • Phone: 305-793-0440
  • Fax: 877-770-1197
Mailing address:
  • Phone: 305-793-0440
  • Fax: 877-770-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberSO-11-1164-GH
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: