MEDICARE: MABATH, 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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29622	OTHER	FL	PT

General Provider Information

NPI Number	:	1679038483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MABATH, LLC.

Provider Business Mailing Address
First Line	:	926 N O ST
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-2746
Country	:	US
Telephone Number	:	407-490-8052
Fax Number	:	305-466-9543

Provider Business Practice Location Address
First Line	:	6971 N FEDERAL HWY STE 205
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33487-1648
Country	:	US
Telephone Number	:	407-490-8052
Fax Number	:	305-466-9543

Authorized Official
Title or Position	:	CREDENTIALING DIRECTOR
Name	:	JORGE GARCIA
Credential	:
Telephone Number	:	305-606-0337

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	07/11/2019

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