Healthcare Provider Details

I. General information

NPI: 1710620885
Provider Name (Legal Business Name): PALM MEDICAL CENTER LAKELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5258 LINTON BLVD STE 301
DELRAY BEACH FL
33484-6539
US

IV. Provider business mailing address

5258 LINTON BLVD STE 301
DELRAY BEACH FL
33484-6539
US

V. Phone/Fax

Practice location:
  • Phone: 561-819-5447
  • Fax: 561-819-5496
Mailing address:
  • Phone: 561-819-5447
  • Fax: 561-819-5496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARMEL N BOSWELL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 813-538-7880