Healthcare Provider Details

I. General information

NPI: 1124712054
Provider Name (Legal Business Name): INNOVATIVE DIABETIC SOLUTIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 07/26/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 GLADES RD STE 240
BOCA RATON FL
33431-6466
US

IV. Provider business mailing address

4317 INTRACOASTAL DRIVE
HIGHLAND BEACH FL
33487
US

V. Phone/Fax

Practice location:
  • Phone: 561-368-2005
  • Fax: 561-338-2178
Mailing address:
  • Phone: 561-715-2493
  • Fax: 561-338-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD ALEXIS CONLEN
Title or Position: OWNER
Credential: MD
Phone: 561-368-2005