Healthcare Provider Details

I. General information

NPI: 1750089009
Provider Name (Legal Business Name): BOOST MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13798 NW 4TH ST STE 311
SUNRISE FL
33325-6227
US

IV. Provider business mailing address

13798 NW 4TH ST STE 311
SUNRISE FL
33325-6227
US

V. Phone/Fax

Practice location:
  • Phone: 754-778-8235
  • Fax:
Mailing address:
  • Phone: 754-778-8235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA RUTLEDGE
Title or Position: CEO
Credential:
Phone: 936-648-5161