MEDICARE: BEIT HATIKVAH, 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	291U00000X	Clinical Medical Laboratory	10D2016961	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10D2016961	OTHER	FL	CLIA - CERTIFICATE OF WAIVER

General Provider Information

NPI Number	:	1417254269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEIT HATIKVAH, LLC

Provider Business Mailing Address
First Line	:	3910 RCA BLVD
Second Line	:	SUITE 1015
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4284
Country	:	US
Telephone Number	:	561-899-4388
Fax Number	:

Provider Business Practice Location Address
First Line	:	3910 RCA BLVD
Second Line	:	SUITE 1015
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4284
Country	:	US
Telephone Number	:	561-899-4388
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. GARY M WILLIAMAS
Credential	:
Telephone Number	:	561-899-4388

Provider Enumeration Date	:	02/14/2011
Last Update Date	:	02/14/2011

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