Healthcare Provider Details

I. General information

NPI: 1215617782
Provider Name (Legal Business Name): CAROLINE PETITDOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SW 85TH AVE
NORTH LAUDERDALE FL
33068-4736
US

IV. Provider business mailing address

PO BOX 290815
DAVIE FL
33329-0815
US

V. Phone/Fax

Practice location:
  • Phone: 954-916-7687
  • Fax:
Mailing address:
  • Phone: 754-802-6276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: