MEDICARE: MEDYTOX MEDICAL MANAGEMENT SOLUTIONS, 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1184922692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDYTOX MEDICAL MANAGEMENT SOLUTIONS, INC

Provider Business Mailing Address
First Line	:	1080 E INDIANTOWN RD
Second Line	:	SUITE 100
City	:	JUPITER
State	:	FL
Zip	:	33477-5100
Country	:	US
Telephone Number	:	561-746-6868
Fax Number	:	561-746-6844

Provider Business Practice Location Address
First Line	:	1080 E INDIANTOWN RD
Second Line	:	SUITE 100
City	:	JUPITER
State	:	FL
Zip	:	33477-5100
Country	:	US
Telephone Number	:	561-746-6868
Fax Number	:	561-746-6844

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MRS. DEBRA ANN BOCCAROSSA
Credential	:
Telephone Number	:	561-746-6868

Provider Enumeration Date	:	03/08/2011
Last Update Date	:	03/08/2011

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