Provider Demographics
NPI:1053736405
Name:FLORIDA ATLANTIC UNIVERSITY
Entity type:Organization
Organization Name:FLORIDA ATLANTIC UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTIROLI-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-297-2897
Mailing Address - Street 1:777 GLADES RD
Mailing Address - Street 2:OFFICE BUILDING 1
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6496
Mailing Address - Country:US
Mailing Address - Phone:561-566-5328
Mailing Address - Fax:561-299-4220
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:OFFICE BUILDING 1
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6496
Practice Address - Country:US
Practice Address - Phone:561-566-5328
Practice Address - Fax:561-299-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2023-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000OtherALZHEIMER'S PREVENTION CLINIC