Healthcare Provider Details

I. General information

NPI: 1619121340
Provider Name (Legal Business Name): BOUTWELL MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3185 BOUTWELL RD
LAKE WORTH FL
33461-2610
US

IV. Provider business mailing address

PO BOX 7240
JUPITER FL
33468-7240
US

V. Phone/Fax

Practice location:
  • Phone: 561-533-0074
  • Fax:
Mailing address:
  • Phone: 561-748-2889
  • Fax: 561-748-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MORGAN PONCY
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 561-748-2889