Healthcare Provider Details

I. General information

NPI: 1568536282
Provider Name (Legal Business Name): LIGHTHOUSE ORTHOPAEDIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9970 CENTRAL PARK BLVD N STE 400
BOCA RATON FL
33428-2236
US

IV. Provider business mailing address

1821 NE 25TH ST
LIGHTHOUSE POINT FL
33064-7744
US

V. Phone/Fax

Practice location:
  • Phone: 561-483-1600
  • Fax: 561-451-4732
Mailing address:
  • Phone: 954-942-0321
  • Fax: 954-946-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number38853A
License Number StateFL

VIII. Authorized Official

Name: MR. THOMAS J GOBERVILLE
Title or Position: PRESIDENT
Credential: MD
Phone: 954-942-0321