Healthcare Provider Details

I. General information

NPI: 1790031300
Provider Name (Legal Business Name): INTERACTIVEMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 BROKEN SOUND BLVD NW SUITE 200
BOCA RATON FL
33487-3520
US

IV. Provider business mailing address

5300 BROKEN SOUND BLVD NW SUITE 200
BOCA RATON FL
33487-3520
US

V. Phone/Fax

Practice location:
  • Phone: 888-657-2560
  • Fax: 561-998-2057
Mailing address:
  • Phone: 888-657-2560
  • Fax: 561-998-2057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY WALD
Title or Position: CHIEF OPERATING OFFICER
Credential: MBA
Phone: 888-657-2560