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General NPI Number Information
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NPI Number | 1639434038
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Entity Type | Organization
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Legal Business Name | DIVERSE MEDICAL CARE LLC
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Dates
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Enumeration Date | 07/11/2012
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Last Update Date | 07/12/2012
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Provider Practice Location Address
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Address Line | 2310 SE 2ND ST SUITE #2
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City | BOYNTON BEACH
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State | FL
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Zip | 33435-7280
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Country | US
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Telephone | 561-509-9382
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Fax | 561-509-9362
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Provider Business Mailing Address
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Address Line | 4215 S FLAGLER DR
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City | WEST PALM BEACH
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State | FL
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Zip | 33405-2705
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Country | US
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Telephone | 561-509-9382
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Fax | 561-509-9362
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Authorized Official
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Title or Position | MANAGER
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Name | MARY N ATALLA
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Credential |
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Telephone | 561-509-9382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | PMC 1223
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License Number State | FL
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