Provider Demographics
NPI:1467958082
Name:MEDICAL SERVICE GROUP LLC
Entity Type:Organization
Organization Name:MEDICAL SERVICE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-337-7976
Mailing Address - Street 1:6801 LAKE WORTH RD STE 350
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2974
Mailing Address - Country:US
Mailing Address - Phone:561-337-7976
Mailing Address - Fax:
Practice Address - Street 1:11576 PIERSON RD STE K6
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8765
Practice Address - Country:US
Practice Address - Phone:561-337-7976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL56081347114901261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder