Provider Demographics
NPI:1710365051
Name:EXCEPTIONAL CARE CHOICE, LLC
Entity Type:Organization
Organization Name:EXCEPTIONAL CARE CHOICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:GUSTI
Authorized Official - Middle Name:
Authorized Official - Last Name:LABATTE-DENEAU
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:772-333-9319
Mailing Address - Street 1:1632 SW IVY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2248
Mailing Address - Country:US
Mailing Address - Phone:917-207-4785
Mailing Address - Fax:
Practice Address - Street 1:1632 SW IVY ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2248
Practice Address - Country:US
Practice Address - Phone:917-207-4785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9263802363LA2200X
363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016402900Medicaid