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General NPI Number Information
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NPI Number | 1932553880
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Entity Type | Organization
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Legal Business Name | JACOB PISTOR
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Dates
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Enumeration Date | 04/18/2016
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Last Update Date | 04/18/2016
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Provider Practice Location Address
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Address Line | 4895 WINDWARD PASSAGE DR STE 6
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City | BOYNTON BEACH
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State | FL
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Zip | 33436-7741
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Country | US
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Telephone | 561-877-8753
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Fax |
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Provider Business Mailing Address
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Address Line | 4895 WINDWARD PASSAGE DR STE 6
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City | BOYNTON BEACH
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State | FL
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Zip | 33436-7741
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Country | US
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Telephone | 561-877-8753
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACOB PISTOR
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Credential |
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Telephone | 954-727-6605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | FL
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