Provider Demographics
NPI:1639496664
Name:DR. ROYCE JALAZO, P.A.
Entity type:Organization
Organization Name:DR. ROYCE JALAZO, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:JALAZO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:954-232-7092
Mailing Address - Street 1:1975 E SUNRISE BLVD
Mailing Address - Street 2:SUITE 532
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1433
Mailing Address - Country:US
Mailing Address - Phone:954-232-7092
Mailing Address - Fax:954-208-3400
Practice Address - Street 1:1975 E SUNRISE BLVD
Practice Address - Street 2:SUITE 532
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1433
Practice Address - Country:US
Practice Address - Phone:954-232-7092
Practice Address - Fax:954-208-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-30
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7671103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBM191XMedicare UPIN