Healthcare Provider Details

I. General information

NPI: 1487004057
Provider Name (Legal Business Name): BROKEN BUT RESTORED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3179 W ATLANTIC BLVD STE 35
POMPANO BEACH FL
33069-2565
US

IV. Provider business mailing address

3179 W ATLANTIC BLVD STE 35
POMPANO BEACH FL
33069-2565
US

V. Phone/Fax

Practice location:
  • Phone: 754-244-7051
  • Fax:
Mailing address:
  • Phone: 754-244-7051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: GENIKA BYRD
Title or Position: OWNER/CORDINATOR
Credential:
Phone: 754-244-7051