Provider Demographics
NPI:1952127482
Name:BOTSOE, RENE K
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:K
Last Name:BOTSOE
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 1:97013 HARBOR CONCOURSE CIR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3868
Mailing Address - Country:US
Mailing Address - Phone:585-414-0994
Mailing Address - Fax:
Practice Address - Street 1:97013 HARBOR CONCOURSE CIR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3868
Practice Address - Country:US
Practice Address - Phone:585-414-0994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
FL320731691220347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)