Basic Information
| Provider Information | |||||||||
| NPI: | 1992375281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMICUS MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1300 CONCORD TER STE 210 | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545055000 | ||||||||
| FaxNumber: | 9548389660 | ||||||||
| Practice Location | |||||||||
| Address1: | 3795 W BOYNTON BEACH BLVD STE D | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334364502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617387900 | ||||||||
| FaxNumber: | 5613693254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ECHEVARRIA | ||||||||
| AuthorizedOfficialFirstName: | HERIKA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9545055000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.