Healthcare Provider Details

I. General information

NPI: 1649895095
Provider Name (Legal Business Name): BDMJ HOLDINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 LAKE IDA RD STE 2
DELRAY BEACH FL
33445-2443
US

IV. Provider business mailing address

2150 LAKE IDA RD STE 2
DELRAY BEACH FL
33445-2443
US

V. Phone/Fax

Practice location:
  • Phone: 561-425-2310
  • Fax:
Mailing address:
  • Phone: 561-425-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES EDWARD JARVIS IV
Title or Position: MANAGER
Credential:
Phone: 561-425-2310