Healthcare Provider Details

I. General information

NPI: 1053978353
Provider Name (Legal Business Name): PBISM WEST BOCA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21737 STATE ROAD 7
BOCA RATON FL
33428-2822
US

IV. Provider business mailing address

3848 FAU BLVD STE 105
BOCA RATON FL
33431-6437
US

V. Phone/Fax

Practice location:
  • Phone: 561-997-5210
  • Fax: 561-331-2542
Mailing address:
  • Phone: 561-395-2920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRAD VAN PELT
Title or Position: PRESIDENT
Credential:
Phone: 561-395-2920