Healthcare Provider Details

I. General information

NPI: 1992157689
Provider Name (Legal Business Name): MARIE LOUIS ADMINISTRATOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BURNING WICK PL
PALM COAST FL
32137-8802
US

IV. Provider business mailing address

19 BURNING WICK PL
PALM COAST FL
32137-8802
US

V. Phone/Fax

Practice location:
  • Phone: 386-631-0432
  • Fax:
Mailing address:
  • Phone: 386-631-0432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number6906826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: