Basic Information
| Provider Information | |||||||||
| NPI: | 1750988176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOMA MEDICAL CENTER, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOMA WELLHEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 FOREST HILL BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612757110 | ||||||||
| FaxNumber: | 5612757130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 ROYAL PALM BEACH BLVD BLDG 100 | ||||||||
| Address2: | |||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334111691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616297897 | ||||||||
| FaxNumber: | 5613234033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2020 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLOREZ | ||||||||
| AuthorizedOfficialFirstName: | ANDRES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5612757110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOMA MEDICAL CENTER, PA | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 106486900 | 05 | FL | MEDICAID |