Healthcare Provider Details

I. General information

NPI: 1104071539
Provider Name (Legal Business Name): ADAM KEITH LAX RD/LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 PALM BEACH LAKES BLVD
WEST PALM BEACH FL
33401-2302
US

IV. Provider business mailing address

450 MULBERRY GROVE RD
ROYAL PALM BEACH FL
33411-4531
US

V. Phone/Fax

Practice location:
  • Phone: 954-292-5625
  • Fax: 772-334-8781
Mailing address:
  • Phone: 954-292-5625
  • Fax: 772-334-8781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND2293
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License NumberND2293
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: