Healthcare Provider Details

I. General information

NPI: 1124538996
Provider Name (Legal Business Name): FOUNDATION MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 11/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NW 101ST LN STE 101
CORAL SPRINGS FL
33065
US

IV. Provider business mailing address

3000 NW 101ST LN STE 101
CORAL SPRINGS FL
33065-3930
US

V. Phone/Fax

Practice location:
  • Phone: 561-674-2696
  • Fax: 561-370-7899
Mailing address:
  • Phone: 954-272-4072
  • Fax: 954-255-9553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. EVAN M KAISER
Title or Position: MANAGER
Credential:
Phone: 954-272-4072