Healthcare Provider Details

I. General information

NPI: 1558735290
Provider Name (Legal Business Name): ADVANTAGE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NORTHPOINT PKWY SUITE 302
WEST PALM BEACH FL
33407-1951
US

IV. Provider business mailing address

901 NORTHPOINT PKWY SUITE 302
WEST PALM BEACH FL
33407-1951
US

V. Phone/Fax

Practice location:
  • Phone: 561-352-1587
  • Fax: 561-420-0194
Mailing address:
  • Phone: 561-352-1587
  • Fax: 561-420-0194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME55707
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME55707
License Number StateFL

VIII. Authorized Official

Name: DR. TAYLOR E GAINES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHARM.D.,C.A.P.
Phone: 561-352-1587