1013166248 NPI number — DELRAY TRAUMA ASSOCIATES, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013166248 NPI number — DELRAY TRAUMA ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELRAY TRAUMA ASSOCIATES, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013166248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 480159
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33348-0159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-491-0900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5352 LINTON BLVD
Provider Second Line Business Practice Location Address:
TRAUMA SERVICES
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33484-6514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-495-3166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PUENTE
Authorized Official First Name:
IVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-491-0900

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME55971 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)