Provider Demographics
NPI:1366730129
Name:BOCA FAMILY MEDICAL GROUP CORP
Entity type:Organization
Organization Name:BOCA FAMILY MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAIDELE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:561-391-6552
Mailing Address - Street 1:7280 W PALMETTO PARK RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3422
Mailing Address - Country:US
Mailing Address - Phone:561-391-6552
Mailing Address - Fax:561-391-6285
Practice Address - Street 1:7280 W PALMETTO PARK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3422
Practice Address - Country:US
Practice Address - Phone:561-391-6552
Practice Address - Fax:561-391-6285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty