Provider Demographics
NPI:1538155262
Name:COMPLETE LOCAL SPECIALTY CARE, INC
Entity type:Organization
Organization Name:COMPLETE LOCAL SPECIALTY CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:954-418-1683
Mailing Address - Street 1:4855 W. HILLSBORO BLVD STE B2
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4356
Mailing Address - Country:US
Mailing Address - Phone:954-418-1683
Mailing Address - Fax:
Practice Address - Street 1:5355 LYONS RD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-2825
Practice Address - Country:US
Practice Address - Phone:954-570-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74562OtherMEDICARE PTAN
FL268799200Medicaid