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General NPI Number Information
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NPI Number | 1417370784
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Entity Type | Organization
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Legal Business Name | MASSARA MEDICAL CENTER,LLC
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Dates
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Enumeration Date | 01/22/2014
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Last Update Date | 01/22/2014
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Provider Practice Location Address
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Address Line | 455 NE 5TH AVE SUITE D -297
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City | DELRAY BEACH
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State | FL
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Zip | 33483-5658
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Country | US
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Telephone | 772-233-9515
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Fax |
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Provider Business Mailing Address
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Address Line | 455 NE 5TH AVE SUITE D -297
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City | DELRAY BEACH
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State | FL
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Zip | 33483-5658
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Country | US
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Telephone | 772-233-9515
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Fax |
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Authorized Official
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Title or Position | CEO/CMO
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Name | DR. LORETHA KING
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Credential | DO
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Telephone | 772-233-9515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OS8310
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License Number State | FL
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