Healthcare Provider Details

I. General information

NPI: 1235400938
Provider Name (Legal Business Name): OUR PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4699 N FEDERAL HWY SUITE 206A
POMPANO BEACH FL
33064-6510
US

IV. Provider business mailing address

460 S OCEAN DR
DEERFIELD BEACH FL
33441-5125
US

V. Phone/Fax

Practice location:
  • Phone: 888-976-2379
  • Fax: 954-719-6762
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1706AD870001
License Number StateFL

VIII. Authorized Official

Name: JOSE FLORES
Title or Position: BILLING COORDINATOR
Credential:
Phone: 754-201-2265