Healthcare Provider Details

I. General information

NPI: 1053580027
Provider Name (Legal Business Name): SOUTHWEST BROWARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18503 PINES BLVD SUITE 305
PEMBROKE PINES FL
33029-1404
US

IV. Provider business mailing address

18503 PINES BLVD SUITE 305
PEMBROKE PINES FL
33029-1404
US

V. Phone/Fax

Practice location:
  • Phone: 954-392-1851
  • Fax:
Mailing address:
  • Phone: 954-392-1851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number12267
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number12267
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number12267
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number12267
License Number StateFL

VIII. Authorized Official

Name: DR. ALVARO BETANCUR
Title or Position: PRESIDENT
Credential:
Phone: 954-392-1851