=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144955444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MULTI SPECIALTY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2022
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8682 TOURMALINE BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33472-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-777-4402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8682 TOURMALINE BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33472-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-777-4402
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER
-----------------------------------------------------
Name | LISETTE TEN HOOPEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-777-4402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------