Basic Information
| Provider Information | |||||||||
| NPI: | 1497415053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUPITER WEST MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2632 W INDIANTOWN RD | ||||||||
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| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334585889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617447373 | ||||||||
| FaxNumber: | 8007835176 | ||||||||
| Practice Location | |||||||||
| Address1: | 10377 S US HIGHWAY 1 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723371300 | ||||||||
| FaxNumber: | 8007835176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2021 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | OSWALD | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5612363741 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000647406 | 05 | FL | MEDICAID |