=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629637848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELET CAZEAU ADMINISTRATOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2019
-----------------------------------------------------
Last Update Date | 11/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 724 CHINA BERRY CIR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-463-9079
-----------------------------------------------------
Fax | 863-837-4410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 724 CHINA BERRY CIR
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33837-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-463-9079
-----------------------------------------------------
Fax | 863-837-4410
-----------------------------------------------------
=====================================================
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 | 6906977
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------