Provider Demographics
NPI:1972688992
Name:BOARD OF TRUSTEES OF FLORIDA ATLANTIC UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF FLORIDA ATLANTIC UNIVERSITY
Other - Org Name:FLORIDA ATLANTIC UNIVERSITY STUDENT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIROLI-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-297-2897
Mailing Address - Street 1:777 GLADES RD
Mailing Address - Street 2:STUDENT HEALTH, BLDG SS-8W, ROOM 235
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6424
Mailing Address - Country:US
Mailing Address - Phone:561-297-0704
Mailing Address - Fax:561-297-0221
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:STUDENT HEALTH, BLDG SS-8W, ROOM 235
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-0991
Practice Address - Country:US
Practice Address - Phone:561-297-0704
Practice Address - Fax:561-297-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNOT REQUIRED261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
110OtherAMERICAN COLL HLTH ASSOC