Provider Demographics
NPI:1164565446
Name:LUCILLE BESELER LD RD PA
Entity Type:Organization
Organization Name:LUCILLE BESELER LD RD PA
Other - Org Name:FAMILY NUTRITION CENTER OF SOUTH FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BESELER
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD CDE
Authorized Official - Phone:954-972-2123
Mailing Address - Street 1:5901 COLONIAL DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5675
Mailing Address - Country:US
Mailing Address - Phone:954-972-2123
Mailing Address - Fax:954-972-4567
Practice Address - Street 1:5901 COLONIAL DR
Practice Address - Street 2:SUITE 108
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5675
Practice Address - Country:US
Practice Address - Phone:954-972-2123
Practice Address - Fax:954-972-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLN2042133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3348Medicare ID - Type Unspecified