Healthcare Provider Details

I. General information

NPI: 1710515564
Provider Name (Legal Business Name): PCP 1ST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 03/28/2020
Certification Date: 03/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17188 NEWPORT CLUB DR
BOCA RATON FL
33496-3009
US

IV. Provider business mailing address

2901 CLINT MOORE RD # 119
BOCA RATON FL
33496-2041
US

V. Phone/Fax

Practice location:
  • Phone: 954-803-3564
  • Fax:
Mailing address:
  • Phone: 954-803-3564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: YEENY GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 954-803-3564