Provider Demographics
NPI:1295786523
Name:BROOKE PARK CLINIC
Entity type:Organization
Organization Name:BROOKE PARK CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:SHUMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-496-0333
Mailing Address - Street 1:4455 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-5830
Mailing Address - Country:US
Mailing Address - Phone:561-496-0333
Mailing Address - Fax:561-998-4886
Practice Address - Street 1:4455 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-5830
Practice Address - Country:US
Practice Address - Phone:561-496-0333
Practice Address - Fax:561-998-4886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003610103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5287Medicare ID - Type Unspecified