Provider Demographics
NPI:1093101784
Name:ISLAND LIFE MD LLC
Entity Type:Organization
Organization Name:ISLAND LIFE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-740-5746
Mailing Address - Street 1:1015 SPANISH RIVER RD APT 202
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-7607
Mailing Address - Country:US
Mailing Address - Phone:215-740-5746
Mailing Address - Fax:
Practice Address - Street 1:9970 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 102
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2231
Practice Address - Country:US
Practice Address - Phone:561-430-3599
Practice Address - Fax:561-430-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty