MEDICARE: POP'S HOUSE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	10D2039731	FL

General Provider Information

NPI Number	:	1336495290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POP'S HOUSE LLC

Provider Business Mailing Address
First Line	:	4101 NE 13TH AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6040
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Provider Business Practice Location Address
First Line	:	4101 NE 13TH AVE
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6040
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Authorized Official
Title or Position	:	OWNER
Name	:	EDGARDO VEGA
Credential	:
Telephone Number	:	954-746-8232

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	01/07/2014

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Directions to “POP'S HOUSE LLC ” Practice Location

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