Healthcare Provider Details

I. General information

NPI: 1508376641
Provider Name (Legal Business Name): CONRAD THEINER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 2ND AVE N
PALM SPRINGS FL
33461
US

IV. Provider business mailing address

691 MANATEE BAY DR
BOYNTON BEACH FL
33435-2800
US

V. Phone/Fax

Practice location:
  • Phone: 561-357-7779
  • Fax: 561-357-7796
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: