Healthcare Provider Details

I. General information

NPI: 1760867410
Provider Name (Legal Business Name): THERAPEUTIC RECREATIONAL ACTIVITIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N 46TH AVE
HOLLYWOOD FL
33021-6603
US

IV. Provider business mailing address

12335 NW 51ST ST
CORAL SPRINGS FL
33076-3446
US

V. Phone/Fax

Practice location:
  • Phone: 954-873-0962
  • Fax:
Mailing address:
  • Phone: 954-918-2164
  • Fax: 954-369-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP 2113432
License Number StateFL

VIII. Authorized Official

Name: MR. ANTHONY FALDEN
Title or Position: AMBR
Credential:
Phone: 954-918-2164