MEDICARE: IRWIC SOUTH 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	174400000X	Specialist

General Provider Information

NPI Number	:	1386816171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRWIC SOUTH LLC

Provider Business Mailing Address
First Line	:	836 S US HIGHWAY 1
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32962-4703
Country	:	US
Telephone Number	:	772-299-1092
Fax Number	:	772-978-1960

Provider Business Practice Location Address
First Line	:	11327 OKEECHOBEE BLVD
Second Line	:	SUITE 2
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-8724
Country	:	US
Telephone Number	:	561-795-4565
Fax Number	:	561-795-3992

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. JAMES STEPHEN LOBEL
Credential	:
Telephone Number	:	772-299-1092

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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