Healthcare Provider Details

I. General information

NPI: 1548756661
Provider Name (Legal Business Name): BLO 7 DIABETES INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SW HILLMOOR DR. SUITE 305
PORT ST. LUCIE FL
34952
US

IV. Provider business mailing address

9858 CLINT MOORE RD STE C111-131
BOCA RATON FL
33496-1034
US

V. Phone/Fax

Practice location:
  • Phone: 772-486-3812
  • Fax:
Mailing address:
  • Phone: 772-486-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: VANDANA SHAH
Title or Position: CEO
Credential:
Phone: 772-486-3812