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General NPI Number Information
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NPI Number | 1669913430
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Entity Type | Organization
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Legal Business Name | MICHAEL BOMBKA LLC
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Dates
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Enumeration Date | 03/14/2017
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Last Update Date | 03/14/2017
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Provider Practice Location Address
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Address Line | 2605 W LAKE MARY BLVD
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City | LAKE MARY
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State | FL
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Zip | 32746-3568
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Country | US
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Telephone | 407-463-4907
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Fax |
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Provider Business Mailing Address
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Address Line | 108 HOMESTEAD AVE
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City | DEBARY
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State | FL
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Zip | 32713-3816
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Country | US
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Telephone | 407-463-4907
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MICHAEL ALLAN BOMBKA
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Credential |
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Telephone | 407-463-4907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | MH7297
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License Number State | FL
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