Healthcare Provider Details

I. General information

NPI: 1740590181
Provider Name (Legal Business Name): MLEAC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 METROCENTRE BLVD SUITE 1
WEST PALM BEACH FL
33407-3100
US

IV. Provider business mailing address

4774 S CLASSICAL BLVD
DELRAY BEACH FL
33445-1225
US

V. Phone/Fax

Practice location:
  • Phone: 561-684-2022
  • Fax: 561-455-2696
Mailing address:
  • Phone: 561-346-9162
  • Fax: 561-455-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7384
License Number StateFL

VIII. Authorized Official

Name: MS. MARY LYNN ENGROFF
Title or Position: PRESIDENT
Credential: PT, PA-C
Phone: 561-346-9162