1215271572 NPI number — THRIVE WELLNESS CENTER OF BOCA RATON, LLC

Table of content: (NPI 1215271572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215271572 NPI number — THRIVE WELLNESS CENTER OF BOCA RATON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE WELLNESS CENTER OF BOCA RATON, 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:
6
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:
1215271572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1244 S FEDERAL HWY
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:
33316-2074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-713-6118
Provider Business Mailing Address Fax Number:
954-337-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2499 GLADES RD
Provider Second Line Business Practice Location Address:
SUITE 305-A
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33431-7209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-713-6118
Provider Business Practice Location Address Fax Number:
954-337-2996
Provider Enumeration Date:
11/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
954-713-6118

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , 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)





Copyright © 2007-2025 www.npivalidator.com