Healthcare Provider Details

I. General information

NPI: 1033507330
Provider Name (Legal Business Name): JPLRC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 INTRACOASTAL POINTE DR
JUPITER FL
33477-5036
US

IV. Provider business mailing address

108 INTRACOASTAL POINTE DR STE 300
JUPITER FL
33477-5036
US

V. Phone/Fax

Practice location:
  • Phone: 561-529-4494
  • Fax:
Mailing address:
  • Phone: 561-529-4494
  • Fax: 561-529-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberME111506
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME111506
License Number StateFL

VIII. Authorized Official

Name: DR. MATTHEW HARRIS
Title or Position: MEDICAL DIRECTOR, SOLE PROPRIETOR
Credential: MD
Phone: 347-891-1546