Healthcare Provider Details

I. General information

NPI: 1881925352
Provider Name (Legal Business Name): CLASSICAL ORIENTAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2010
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3459 W WOOLBRIGHT RD
BOYNTON BEACH FL
33436-7246
US

IV. Provider business mailing address

3459 W WOOLBRIGHT RD
BOYNTON BEACH FL
33436-7246
US

V. Phone/Fax

Practice location:
  • Phone: 561-932-3905
  • Fax:
Mailing address:
  • Phone: 561-932-3905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberAP2398
License Number StateFL

VIII. Authorized Official

Name: DR. NELYA DE BRUN
Title or Position: OWNER
Credential:
Phone: 561-932-3905