Healthcare Provider Details

I. General information

NPI: 1740686393
Provider Name (Legal Business Name): SOLARA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 GLADES RD SUITE 324 A
BOCA RATON FL
33431-7382
US

IV. Provider business mailing address

850 CENTRAL PKWY E SUITE 275
PLANO TX
75074-5561
US

V. Phone/Fax

Practice location:
  • Phone: 972-372-1663
  • Fax:
Mailing address:
  • Phone: 972-372-1663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. VIVEK SASTRY
Title or Position: OWNER
Credential:
Phone: 972-372-1663