=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831669241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECONNECT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2018
-----------------------------------------------------
Last Update Date | 11/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4110 KEY LIME BLVD
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-414-9326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7260 W AZURE DR STE 140-2536
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89130-7999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-414-9326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ANGELA ELLEN OPALAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-414-9326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------