Healthcare Provider Details

I. General information

NPI: 1144599283
Provider Name (Legal Business Name): ELISE ROUBICEK HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 SAXON BLVD STE 102
ORANGE CITY FL
32763-8357
US

IV. Provider business mailing address

902 SAXON BLVD STE 102
ORANGE CITY FL
32763-8357
US

V. Phone/Fax

Practice location:
  • Phone: 386-917-0001
  • Fax: 386-917-0008
Mailing address:
  • Phone: 386-917-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS3775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: