Healthcare Provider Details

I. General information

NPI: 1538773023
Provider Name (Legal Business Name): GENTERA MED BOCA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7815 NW BEACON SQUARE BLVD STE 101
BOCA RATON FL
33487-1345
US

IV. Provider business mailing address

7815 NW BEACON SQUARE BLVD STE 101
BOCA RATON FL
33487-1345
US

V. Phone/Fax

Practice location:
  • Phone: 561-475-3877
  • Fax: 561-334-2956
Mailing address:
  • Phone: 561-475-3877
  • Fax: 561-334-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SASHA CONNOLLY
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 617-568-0475