=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265777262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PULMONARY CC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2012
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10075 S JOG RD 311
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-777-5308
-----------------------------------------------------
Fax | 561-303-2131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6615 W BOYNTON BEACH BLVD PMB 101
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-777-5308
-----------------------------------------------------
Fax | 561-303-2131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WAMBURA N. MKONO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-777-5308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | ME110611
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------