Provider Demographics
NPI:1639434038
Name:DIVERSE MEDICAL CARE LLC
Entity Type:Organization
Organization Name:DIVERSE MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:ATALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-509-9382
Mailing Address - Street 1:4215 S FLAGLER DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-2705
Mailing Address - Country:US
Mailing Address - Phone:561-509-9382
Mailing Address - Fax:561-509-9362
Practice Address - Street 1:2310 SE 2ND ST
Practice Address - Street 2:SUITE #2
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7280
Practice Address - Country:US
Practice Address - Phone:561-509-9382
Practice Address - Fax:561-509-9362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMC 1223208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty