=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235935438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA BONNE SANTE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10833 S JOG ROAD SUITE 160
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-910-2652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12361 HAGEN RANCH RD UNIT 503
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SARGINE BRUTUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-324-1781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------