Healthcare Provider Details

I. General information

NPI: 1043465479
Provider Name (Legal Business Name): JOY DEBUSK OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 GREENBORO DR
WEST MELBOURNE FL
32904-1698
US

IV. Provider business mailing address

2674 TUSCARORA CT
WEST MELBOURNE FL
32904-8091
US

V. Phone/Fax

Practice location:
  • Phone: 321-821-6736
  • Fax:
Mailing address:
  • Phone: 321-729-6580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOTA 10480
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: