Provider Demographics
NPI:1043579618
Name:LAKE WORTH PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:LAKE WORTH PHYSICAL MEDICINE
Other - Org Name:PALM BEACH PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-729-7089
Mailing Address - Street 1:PO BOX 16836
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33416-6836
Mailing Address - Country:US
Mailing Address - Phone:561-868-5668
Mailing Address - Fax:561-868-5702
Practice Address - Street 1:1722-A SOUTH CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461
Practice Address - Country:US
Practice Address - Phone:561-868-5668
Practice Address - Fax:561-868-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty