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General NPI Number Information
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NPI Number | 1790031300
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Entity Type | Organization
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Legal Business Name | INTERACTIVEMD LLC
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Dates
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Enumeration Date | 08/01/2012
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Last Update Date | 08/01/2012
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Provider Practice Location Address
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Address Line | 5300 BROKEN SOUND BLVD NW SUITE 200
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City | BOCA RATON
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State | FL
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Zip | 33487-3520
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Country | US
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Telephone | 888-657-2560
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Fax | 561-998-2057
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Provider Business Mailing Address
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Address Line | 5300 BROKEN SOUND BLVD NW SUITE 200
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City | BOCA RATON
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State | FL
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Zip | 33487-3520
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Country | US
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Telephone | 888-657-2560
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Fax | 561-998-2057
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | MR. GARY WALD
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Credential | MBA
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Telephone | 888-657-2560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1006X
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Taxonomy Name | Metabolic Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163WD0400X
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Taxonomy Name | Diabetes Educator Registered Nurse
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License Number |
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License Number State |
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