Healthcare Provider Details

I. General information

NPI: 1235430513
Provider Name (Legal Business Name): COLUMNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 LANTANA RD STE 201
LAKE WORTH FL
33462-2247
US

IV. Provider business mailing address

3618 LANTANA RD STE 201
LAKE WORTH FL
33462-2247
US

V. Phone/Fax

Practice location:
  • Phone: 561-296-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME105711
License Number StateFL

VIII. Authorized Official

Name: THOMAS ROUSH
Title or Position: OWNER
Credential:
Phone: 561-531-2401