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General NPI Number Information
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NPI Number | 1508096330
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Entity Type | Organization
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Legal Business Name | 360 MEDICAL PA
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Dates
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Enumeration Date | 07/14/2009
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Last Update Date | 08/04/2009
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Provider Practice Location Address
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Address Line | 2004 NE 49TH ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-4524
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Country | US
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Telephone | 954-790-2251
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Fax | 954-206-2200
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Provider Business Mailing Address
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Address Line | 2004 NE 49TH ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-4524
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Country | US
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Telephone | 954-790-2251
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Fax | 954-206-2200
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LAN T PHAN
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Credential | DO
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Telephone | 954-790-2251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | OS7637
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License Number State | FL
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