Healthcare Provider Details

I. General information

NPI: 1720534753
Provider Name (Legal Business Name): MRS. KAEGAN BLOMSETH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14335 SW 120TH ST SUITE 201
MIAMI FL
33186-7294
US

IV. Provider business mailing address

14335 SW 120TH ST SUITE 201
MIAMI FL
33186-7294
US

V. Phone/Fax

Practice location:
  • Phone: 305-967-8074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: