Provider Demographics
NPI:1174836092
Name:DFDFDF
Entity Type:Organization
Organization Name:DFDFDF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOC
Authorized Official - Prefix:DR
Authorized Official - First Name:DFDFDFD
Authorized Official - Middle Name:DFD
Authorized Official - Last Name:FDFDFDF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-412-2015
Mailing Address - Street 1:7156 COLONY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7156 COLONY CLUB DR
Practice Address - Street 2:309
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7836
Practice Address - Country:US
Practice Address - Phone:561-420-5120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8666283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital