=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124630892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOSELENE BELIZAIRE SOLE PROPRIETOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2020
-----------------------------------------------------
Last Update Date | 09/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3411 9TH ST W
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33971-5357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-258-6862
-----------------------------------------------------
Fax | 239-362-1561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3411 9TH ST W
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33971-5357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-258-6862
-----------------------------------------------------
Fax | 239-362-1561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6907016
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------