Provider Demographics
NPI:1417494154
Name:SHENANDOAH MEDICAL CARE CENTER
Entity Type:Organization
Organization Name:SHENANDOAH MEDICAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:561-853-7233
Mailing Address - Street 1:PO BOX 741424
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33474-1424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6234 S CONGRESS AVE
Practice Address - Street 2:SUITE F-1
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-2307
Practice Address - Country:US
Practice Address - Phone:561-619-9510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2602122261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010866400Medicaid
FLCE016ZMedicare UPIN