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General NPI Number Information
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NPI Number | 1245615863
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Entity Type | Organization
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Legal Business Name | 2110 WEST PALM FACILITY,LLC
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Dates
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Enumeration Date | 07/24/2015
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Last Update Date | 04/14/2016
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Provider Practice Location Address
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Address Line | 2110 N FLORIDA MANGO RD
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City | WEST PALM BEACH
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State | FL
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Zip | 33409-6492
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Country | US
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Telephone | 561-404-5871
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Fax | 561-318-6413
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Provider Business Mailing Address
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Address Line | 2110 N FLORIDA MANGO RD
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City | WEST PALM BEACH
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State | FL
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Zip | 33409-6492
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Country | US
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Telephone | 561-404-5871
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Fax | 561-318-6413
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Authorized Official
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Title or Position | OWNER
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Name | LARRY HAWKINS
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Credential |
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Telephone | 561-832-4780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 10D2032848
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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