Healthcare Provider Details

I. General information

NPI: 1316412836
Provider Name (Legal Business Name): OSTEOPATHIC MEDICAL ARTS CENTER OF SOUTH FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 WASHINGTON ST STE 401
HOLLYWOOD FL
33021-8249
US

IV. Provider business mailing address

1201 NE 26TH ST STE 109
WILTON MANORS FL
33305-1206
US

V. Phone/Fax

Practice location:
  • Phone: 954-955-6622
  • Fax: 888-809-1631
Mailing address:
  • Phone: 954-838-1173
  • Fax: 888-809-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SERGE GARDERE
Title or Position: OWNER
Credential: DO
Phone: 954-381-7334