Basic Information
| Provider Information | |||||||||
| NPI: | 1811001860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE OUTPATIENT CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE OUTPATIENT CENTER OF BOYNTON BEACH, LTD. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2351S SEACREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334356759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617325900 | ||||||||
| FaxNumber: | 5617327667 | ||||||||
| Practice Location | |||||||||
| Address1: | 2531 SOUTH SEACREST BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617325900 | ||||||||
| FaxNumber: | 5617327667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | JENETHA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9726926745 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 944 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 079186500 | 05 | FL | MEDICAID |