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General NPI Number Information
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NPI Number | 1366812943
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Entity Type | Organization
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Legal Business Name | PB MEDICAL GROUP LLC
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Dates
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Enumeration Date | 09/25/2015
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Last Update Date | 09/28/2015
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Provider Practice Location Address
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Address Line | 2290 10TH AVE N STE 201
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City | LAKE WORTH
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State | FL
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Zip | 33461-6609
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Country | US
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Telephone | 561-225-2890
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Fax |
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Provider Business Mailing Address
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Address Line | 2290 10TH AVE N STE 201
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City | LAKE WORTH
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State | FL
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Zip | 33461-6609
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-FOUNDER AND CEO
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Name | COLIN DAVIS WALLACE
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Credential | MBR
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Telephone | 561-255-4135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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