1033392782 NPI number — FAMILY PRACTICE & INTERNAL MEDICINE OF THE PALM BEACHES LLC

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 1033392782 NPI number — FAMILY PRACTICE & INTERNAL MEDICINE OF THE PALM BEACHES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRACTICE & INTERNAL MEDICINE OF THE PALM BEACHES LLC
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:
1033392782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3401 PGA BLVD STE 430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-2825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-776-8891
Provider Business Mailing Address Fax Number:
561-776-8503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 PGA BLVD
Provider Second Line Business Practice Location Address:
SUITE 430
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-2825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-776-8891
Provider Business Practice Location Address Fax Number:
561-776-8503
Provider Enumeration Date:
12/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCIBELLA
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-776-8891

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME87728 , 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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