Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH5524 | FL |
NPI | 1629499041 |
---|---|
Provider Name | Dr. Mark Shader |
First Address | Boca Raton, FL 33487-4166 |
Second Address | Boca Raton, FL 33487-4166 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2014 |
Last Update Date | 02/01/2014 |