Provider Demographics
NPI:1003276635
Name:PATH MEDICAL, LLC
Entity Type:Organization
Organization Name:PATH MEDICAL, LLC
Other - Org Name:PATH MEDICAL- PORT ST. LUCIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MEDICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNARDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:754-218-2164
Mailing Address - Street 1:2304 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1422
Mailing Address - Country:US
Mailing Address - Phone:754-218-2164
Mailing Address - Fax:954-473-0029
Practice Address - Street 1:549 NW LAKE WHITNEY PL STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1606
Practice Address - Country:US
Practice Address - Phone:772-732-7874
Practice Address - Fax:772-300-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC10776OtherSTATE LICENSE