Basic Information
| Provider Information | |||||||||
| NPI: | 1073517504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH CARE DISTRICT OF PALM BEACH COUNTY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTH CARE DISTRICT -TRAUMA HAWK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N FLAGLER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334013429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5617336663 | ||||||||
| Practice Location | |||||||||
| Address1: | 4255 SOUTHERN BLVD | ||||||||
| Address2: | BLDG 1625-B, SUITE 307 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334061415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
| FaxNumber: | 5616714669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5618045885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416A0800X | Y | Transportation Services | Ambulance | Air Transport |
ID Information
| ID | Type | State | Issuer | Description | 420003900 | 05 | FL | MEDICAID |