Provider Demographics
NPI:1447740840
Name:JOSEPH, WILZADE
Entity Type:Individual
Prefix:
First Name:WILZADE
Middle Name:
Last Name:JOSEPH
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 1:22319 SW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-6010
Mailing Address - Country:US
Mailing Address - Phone:954-793-6290
Mailing Address - Fax:
Practice Address - Street 1:22319 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:954-793-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171239824311ZA0620X, 310400000X, 3104A0625X, 3104A0630X, 311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility