Provider Demographics
NPI:1508092263
Name:LICE SOURCE SERVICES, INC.
Entity Type:Organization
Organization Name:LICE SOURCE SERVICES, INC.
Other - Org Name:SOUTH FLORIDA FAMILY HEALTH & RESEARCH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-791-0711
Mailing Address - Street 1:6971 W SUNRISE BLVD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33313-4407
Mailing Address - Country:US
Mailing Address - Phone:954-791-0711
Mailing Address - Fax:954-791-4392
Practice Address - Street 1:6971 W SUNRISE BLVD
Practice Address - Street 2:SUITE #102
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33313-4407
Practice Address - Country:US
Practice Address - Phone:954-791-0711
Practice Address - Fax:954-791-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8589261Q00000X, 261QH0100X, 261QM1300X, 261QP2300X, 261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001642200Medicaid