Healthcare Provider Details

I. General information

NPI: 1245615863
Provider Name (Legal Business Name): 2110 WEST PALM FACILITY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 N FLORIDA MANGO RD
WEST PALM BEACH FL
33409-6492
US

IV. Provider business mailing address

2110 N FLORIDA MANGO RD
WEST PALM BEACH FL
33409-6492
US

V. Phone/Fax

Practice location:
  • Phone: 561-404-5871
  • Fax: 561-318-6413
Mailing address:
  • Phone: 561-404-5871
  • Fax: 561-318-6413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number10D2032848
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LARRY HAWKINS
Title or Position: OWNER
Credential:
Phone: 561-832-4780