Basic Information
| Provider Information | |||||||||
| NPI: | 1417485053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROHEALTH SELECT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROHEALTH SELECT, INC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 NW 53RD ST STE 330 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334878281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004880279 | ||||||||
| FaxNumber: | 8669028817 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 NW 53RD ST STE 330 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334878281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004880279 | ||||||||
| FaxNumber: | 8669028817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOURG | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8004880279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 363A00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.