Provider Demographics
NPI:1497035364
Name:ULTIMATE CARE MEDICAL CENTER
Entity Type:Organization
Organization Name:ULTIMATE CARE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:561-969-2112
Mailing Address - Street 1:3898 VIA POINCIANA
Mailing Address - Street 2:SUITE #18
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2951
Mailing Address - Country:US
Mailing Address - Phone:561-969-2112
Mailing Address - Fax:561-641-3113
Practice Address - Street 1:3898 VIA POINCIANA
Practice Address - Street 2:SUITE #18
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2951
Practice Address - Country:US
Practice Address - Phone:561-969-2112
Practice Address - Fax:561-641-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9205733261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1356418875Medicaid