Healthcare Provider Details

I. General information

NPI: 1235547753
Provider Name (Legal Business Name): LIDIA BOJORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S ANDREWS AVE FL 2
FT LAUDERDALE FL
33316-2509
US

IV. Provider business mailing address

2307 W BROWARD BLVD STE 200
FORT LAUDERDALE FL
33312-1417
US

V. Phone/Fax

Practice location:
  • Phone: 954-764-2192
  • Fax:
Mailing address:
  • Phone: 954-792-1010
  • Fax: 954-792-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: