Healthcare Provider Details

I. General information

NPI: 1376768333
Provider Name (Legal Business Name): MICHAEL WEILD LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 HUMMINGBIRD WAY APT 4D
NORTH PALM BEACH FL
33408-5101
US

IV. Provider business mailing address

805 HUMMINGBIRD WAY APT 4D
NORTH PALM BEACH FL
33408-5101
US

V. Phone/Fax

Practice location:
  • Phone: 561-842-7568
  • Fax:
Mailing address:
  • Phone: 561-842-7568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberAL 875
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: