MEDICARE: PATH MEDICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center	HCC8638	FL

General Provider Information

NPI Number	:	1457897241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH MEDICAL, LLC

Provider Business Mailing Address
First Line	:	2304 W OAKLAND PARK BLVD
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1422
Country	:	US
Telephone Number	:	754-218-2164
Fax Number	:	407-730-9928

Provider Business Practice Location Address
First Line	:	11285 SW 211TH ST STE 302
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33189-2213
Country	:	US
Telephone Number	:	386-960-2345
Fax Number	:	386-960-2350

Authorized Official
Title or Position	:	DIRECTOR OF MEDICAL SERVICES
Name	:	DR. NEIL BONNARDALE
Credential	:	D.C.
Telephone Number	:	754-218-2164

Provider Enumeration Date	:	01/17/2017
Last Update Date	:	09/14/2020

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