Healthcare Provider Details

I. General information

NPI: 1144420852
Provider Name (Legal Business Name): PALM BEACH CARDIOVASCULAR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 UNIVERSITY BLVD SUITE 206
JUPITER FL
33458-2788
US

IV. Provider business mailing address

601 UNIVERSITY BLVD SUITE 206
JUPITER FL
33458-2788
US

V. Phone/Fax

Practice location:
  • Phone: 561-627-2210
  • Fax: 561-627-5850
Mailing address:
  • Phone: 561-627-2210
  • Fax: 561-627-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number21776
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number21776
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21776
License Number StateFL

VIII. Authorized Official

Name: DR. AUGUSTO ERNESTO VILLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-627-2210