MEDICARE: PATH MEDICAL, LLC

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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1386185189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH MEDICAL, LLC

Provider Business Mailing Address
First Line	:	2304 W OAKLAND PARK BLVD
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33311-1422
Country	:	US
Telephone Number	:	754-218-2164
Fax Number	:

Provider Business Practice Location Address
First Line	:	14824 N FLORIDA AVE STE A
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-1844
Country	:	US
Telephone Number	:	813-549-4480
Fax Number	:	813-549-4485

Authorized Official
Title or Position	:	DIRECTOR OF MEDICAL SERVICES
Name	:	DR. NEIL BONNARDEL
Credential	:	MD
Telephone Number	:	754-218-2164

Provider Enumeration Date	:	03/13/2017
Last Update Date	:	09/09/2019

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