Provider Demographics
NPI:1811446933
Name:DERUN CLINIC
Entity type:Organization
Organization Name:DERUN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:XIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TONG
Authorized Official - Suffix:
Authorized Official - Credentials:AP
Authorized Official - Phone:561-609-9555
Mailing Address - Street 1:144 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-4920
Mailing Address - Country:US
Mailing Address - Phone:561-609-9555
Mailing Address - Fax:
Practice Address - Street 1:144 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-4920
Practice Address - Country:US
Practice Address - Phone:561-609-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3566305S00000X
FLAP3743305S00000X
FLAP3262305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service