Healthcare Provider Details

I. General information

NPI: 1902334964
Provider Name (Legal Business Name): MR. STEVEN TIBBLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 SW 13TH ST
BOCA RATON FL
33486-5406
US

IV. Provider business mailing address

1112 SW 13TH ST
BOCA RATON FL
33486-5406
US

V. Phone/Fax

Practice location:
  • Phone: 561-475-8163
  • Fax:
Mailing address:
  • Phone: 561-475-8163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberT142-796-93-122-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: