MEDICARE: SEVENTY SEVEN HOUSE

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	10D2052648	FL

General Provider Information

NPI Number	:	1619311750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEVENTY SEVEN HOUSE

Provider Business Mailing Address
First Line	:	183 JOG RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-2343
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 JOG RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-2343
Country	:	US
Telephone Number	:	561-715-9288
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ANGELA IACULLO
Credential	:
Telephone Number	:	561-715-9288

Provider Enumeration Date	:	04/19/2013
Last Update Date	:	04/19/2013

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Directions to “SEVENTY SEVEN HOUSE ” Practice Location

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