=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144873779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WSN NURSING HOME SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2019
-----------------------------------------------------
Last Update Date | 07/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7900 VENTURE CENTER WAY
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-7402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-330-0111
-----------------------------------------------------
Fax | 561-330-7635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6068
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33482-6068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-330-7635
-----------------------------------------------------
Fax | 561-330-7635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM NUTOVITS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-330-0111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------