Provider Demographics
NPI:1154969699
Name:JUPITER LAKES PHYSICIAN GROUP PA
Entity type:Organization
Organization Name:JUPITER LAKES PHYSICIAN GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-398-3661
Mailing Address - Street 1:210 JUPITER LAKES BLVD STE 4104
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7190
Mailing Address - Country:US
Mailing Address - Phone:561-744-3467
Mailing Address - Fax:561-748-3272
Practice Address - Street 1:210 JUPITER LAKES BLVD STE 4104
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7190
Practice Address - Country:US
Practice Address - Phone:561-744-3467
Practice Address - Fax:561-748-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care