Provider Demographics
NPI:1124553771
Name:OCTAVE, CHARITE
Entity Type:Individual
Prefix:
First Name:CHARITE
Middle Name:
Last Name:OCTAVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 NW 30TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3390 NW 30TH ST APT 10
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1136
Practice Address - Country:US
Practice Address - Phone:772-882-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor