Healthcare Provider Details

I. General information

NPI: 1629692736
Provider Name (Legal Business Name): MICHELE M GAVIN OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 KAISER AVE
SAINT CLOUD FL
34772-7311
US

IV. Provider business mailing address

4701 OLD CANOE CREEK RD UNIT 702121
SAINT CLOUD FL
34770-7086
US

V. Phone/Fax

Practice location:
  • Phone: 407-301-8804
  • Fax:
Mailing address:
  • Phone: 407-301-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number6969062
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: