Healthcare Provider Details

I. General information

NPI: 1487361358
Provider Name (Legal Business Name): SISTA EMPOWHER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11797 SW 16TH ST
PEMBROKE PINES FL
33025-3791
US

IV. Provider business mailing address

11797 SW 16TH ST
PEMBROKE PINES FL
33025-3791
US

V. Phone/Fax

Practice location:
  • Phone: 754-303-8480
  • Fax:
Mailing address:
  • Phone: 754-303-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number
License Number State

VIII. Authorized Official

Name: KETLY CLEOPHAS
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 754-303-8480