Healthcare Provider Details

I. General information

NPI: 1386896173
Provider Name (Legal Business Name): LAKE WORTH CARDIOLOGY CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 03/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4849 LAKE WORTH RD
GREENACRES FL
33463-3455
US

IV. Provider business mailing address

4849 LAKE WORTH RD
GREENACRES FL
33463-3455
US

V. Phone/Fax

Practice location:
  • Phone: 561-433-4446
  • Fax: 561-433-3026
Mailing address:
  • Phone: 561-202-6064
  • Fax: 561-202-6089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME102740
License Number StateFL

VIII. Authorized Official

Name: MRS. ADELINE ETIENNE
Title or Position: MANAGER
Credential:
Phone: 718-972-9712