1669711370 NPI number — JAMES SCAMPOLE

Table of content: (NPI 1669711370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669711370 NPI number — JAMES SCAMPOLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES SCAMPOLE
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:
PALM BEACH FUNCTIONAL MEDICINE
Provider Other Organization Name Type Code:
3
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:
1669711370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 EXECUTIVE CENTER DR
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33401-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-674-1205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 EXECUTIVE CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33401-2917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-674-1205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SCAMPOLE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-674-1205

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH9708 , 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)





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