=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366834939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALM BEACH SPECIALISTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2015
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5752 OKEECHOBEE BLVD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33417-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-392-8645
-----------------------------------------------------
Fax | 561-877-5604
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5752 OKEECHOBEE BLVD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33417-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-392-8645
-----------------------------------------------------
Fax | 561-877-5604
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MS. PATTY ANN BUCKLEY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 844-620-9701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------