Healthcare Provider Details

I. General information

NPI: 1740974492
Provider Name (Legal Business Name): WIDLINE CICERON RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 NE 130TH ST
NORTH MIAMI FL
33161-7526
US

IV. Provider business mailing address

241 NW 38TH ST
DEERFIELD BEACH FL
33064-2710
US

V. Phone/Fax

Practice location:
  • Phone: 786-508-5968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRT15084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: