Healthcare Provider Details

I. General information

NPI: 1093224347
Provider Name (Legal Business Name): EMMANUEL CIVIL SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23237 SW 61ST AVE
BOCA RATON FL
33428-2023
US

IV. Provider business mailing address

23237 SW 61ST AVE
BOCA RATON FL
33428-2023
US

V. Phone/Fax

Practice location:
  • Phone: 561-891-3316
  • Fax:
Mailing address:
  • Phone: 561-891-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000263-P.A
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number17-460
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: