MEDICARE: LICE CLEANIQUE, LLC.

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	261QS1000X	Student Health Clinic/Center	HCC8590	FL
2	261Q00000X	Clinic/Center	HCC8590	FL
3	261QH0100X	Health Service Clinic/Center	HCC8590	FL
4	261QM1300X	Multi-Specialty Clinic/Center	HCC8590	FL
5	261QR1100X	Research Clinic/Center	HCC8590	FL
6	261QP2300X	Primary Care Clinic/Center	HCC8590	FL

General Provider Information

NPI Number	:	1558597005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICE CLEANIQUE, LLC.

Provider Business Mailing Address
First Line	:	6971 W SUNRISE BLVD
Second Line	:	SUITE 102
City	:	PLANTATION
State	:	FL
Zip	:	33313-4407
Country	:	US
Telephone Number	:	954-791-0711
Fax Number	:	954-791-4392

Provider Business Practice Location Address
First Line	:	5353 W ATLANTIC AVE
Second Line	:	SUITE 400-A
City	:	DELRAY BEACH
State	:	FL
Zip	:	33484-8102
Country	:	US
Telephone Number	:	561-495-0166
Fax Number	:	561-381-4581

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. LIDIA E SERRANO
Credential	:
Telephone Number	:	954-791-0711

Provider Enumeration Date	:	06/10/2009
Last Update Date	:	10/03/2011

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Directions to “LICE CLEANIQUE, LLC. ” Practice Location

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