Healthcare Provider Details

I. General information

NPI: 1063763944
Provider Name (Legal Business Name): SUPPORTIVE HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 S MILITARY TRL
DELRAY BEACH FL
33484-2610
US

IV. Provider business mailing address

2337 VINTAGE DR
LIGHTHOUSE POINT FL
33064-6089
US

V. Phone/Fax

Practice location:
  • Phone: 561-307-1801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARK GERHARDT
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 561-234-8881