Healthcare Provider Details

I. General information

NPI: 1568912699
Provider Name (Legal Business Name): SOMA MEDICAL CENTER, PA #4
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4623 FOREST HILL BLVD SUITE 112
WEST PALM BEACH FL
33415-7469
US

IV. Provider business mailing address

4623 FOREST HILL BLVD SUITE 112
WEST PALM BEACH FL
33415-7469
US

V. Phone/Fax

Practice location:
  • Phone: 561-433-0080
  • Fax: 561-433-1668
Mailing address:
  • Phone: 561-433-0080
  • Fax: 561-433-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME102127
License Number StateFL

VIII. Authorized Official

Name: LINA NIEMCZYK NIEMCZYK
Title or Position: OFFICE MANAGER
Credential:
Phone: 561-433-0080