1750753851 NPI number — SERENITY BROADMOOR LLC

Table of content: (NPI 1750753851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750753851 NPI number — SERENITY BROADMOOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY BROADMOOR LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750753851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3799 N PINE ISLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33351-6528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 DIXIELAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34982-6706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-468-7235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
STECKLER
Authorized Official First Name:
LONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
954-748-0509

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9190 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115247400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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