Provider Demographics
NPI:1245615863
Name:2110 WEST PALM FACILITY,LLC
Entity Type:Organization
Organization Name:2110 WEST PALM FACILITY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-832-4780
Mailing Address - Street 1:2110 N FLORIDA MANGO RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6492
Mailing Address - Country:US
Mailing Address - Phone:561-404-5871
Mailing Address - Fax:561-318-6413
Practice Address - Street 1:2110 N FLORIDA MANGO RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6492
Practice Address - Country:US
Practice Address - Phone:561-404-5871
Practice Address - Fax:561-318-6413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0405X
FL10D2032848291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical Laboratory