Healthcare Provider Details

I. General information

NPI: 1669925590
Provider Name (Legal Business Name): PRACTITIONERS HEALTHCARE NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9540 HUDSON ST
MIRAMAR FL
33025-4208
US

IV. Provider business mailing address

4788 W COMMERCIAL BLVD
TAMARAC FL
33319-2878
US

V. Phone/Fax

Practice location:
  • Phone: 954-668-0287
  • Fax:
Mailing address:
  • Phone: 954-668-0287
  • Fax: 954-640-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number3112112
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3112112
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number3112112
License Number StateFL

VIII. Authorized Official

Name: MRS. DIANE JOHN
Title or Position: PRESIDENT
Credential: FNP
Phone: 954-668-0287