Provider Demographics
NPI:1689022147
Name:PROVIDER SERVICES OF AMERICA, LLC
Entity type:Organization
Organization Name:PROVIDER SERVICES OF AMERICA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARRISON
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-463-8102
Mailing Address - Street 1:PO BOX 812140
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33481-2140
Mailing Address - Country:US
Mailing Address - Phone:561-463-8102
Mailing Address - Fax:561-331-2707
Practice Address - Street 1:2385 NW EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-8579
Practice Address - Country:US
Practice Address - Phone:561-463-8102
Practice Address - Fax:561-331-2707
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OFFICE COMPOUNDING SOLUTIONS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-25
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16-00063751OtherCITY TAX RECEIPT