=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881120160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUTISCARE SHS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2017
-----------------------------------------------------
Last Update Date | 05/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1898 W HILLSBORO BLVD SUITE H
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-617-8310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 GLADES RD SUITE 220W
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-7386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-617-7063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | FAYE TRAEGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-617-7063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------