Provider Demographics
NPI:1376270728
Name:NRG CLINIC LLC
Entity Type:Organization
Organization Name:NRG CLINIC LLC
Other - Org Name:NRG CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-755-7197
Mailing Address - Street 1:200 W PALMETTO PARK RD STE 306
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-3759
Mailing Address - Country:US
Mailing Address - Phone:561-755-7197
Mailing Address - Fax:
Practice Address - Street 1:200 W PALMETTO PARK RD STE 306
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3759
Practice Address - Country:US
Practice Address - Phone:561-755-7197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty