=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568912699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMA MEDICAL CENTER, PA #4
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 04/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4623 FOREST HILL BLVD SUITE 112
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33415-7469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-433-0080
-----------------------------------------------------
Fax | 561-433-1668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4623 FOREST HILL BLVD SUITE 112
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33415-7469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-433-0080
-----------------------------------------------------
Fax | 561-433-1668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LINA NIEMCZYK NIEMCZYK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-433-0080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME102127
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------