Basic Information
| Provider Information | |||||||||
| NPI: | 1134732712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PALM BEACH BOUTIQUE MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 227 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613188440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 227 PROFESSIONAL WAY | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613188440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASHID | ||||||||
| AuthorizedOfficialFirstName: | BINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5613118844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.