MEDICARE: MRS. ALICE M PAYNE-BLAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	136A00000X	Registered Dietetic Technician	718051	FL

General Provider Information

NPI Number	:	1295088144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICE M PAYNE-BLAKE

Provider Business Mailing Address
First Line	:	540 NE 179TH DR
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-1922
Country	:	US
Telephone Number	:	305-650-9024
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 NE 179TH DR
Second Line	:	MIAMI
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33162-1922
Country	:	US
Telephone Number	:	305-650-9024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2012
Last Update Date	:	10/16/2012

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