MEDICARE: WPB MEDICAL PROVIDER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	3201662	FL

General Provider Information

NPI Number	:	1043625718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WPB MEDICAL PROVIDER, INC.

Provider Business Mailing Address
First Line	:	464 FERN ST
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5818
Country	:	US
Telephone Number	:	561-822-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	464 FERN ST
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5818
Country	:	US
Telephone Number	:	561-822-2000
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. COLLEEN PARKHURST
Credential	:
Telephone Number	:	561-822-2000

Provider Enumeration Date	:	06/21/2014
Last Update Date	:	06/21/2014

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