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General NPI Number Information
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NPI Number | 1174377568
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Entity Type | Organization
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Legal Business Name | BRAVE KIDS PPEC LLC
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Dates
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Enumeration Date | 04/12/2024
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Last Update Date | 04/12/2024
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Provider Practice Location Address
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Address Line | 10168 W SAMPLE RD
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City | CORAL SPRINGS
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State | FL
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Zip | 33065-3938
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Country | US
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Telephone | 754-529-8265
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Fax | 754-529-8256
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Provider Business Mailing Address
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Address Line | 10168 W SAMPLE RD
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City | CORAL SPRINGS
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State | FL
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Zip | 33065-3938
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Country | US
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Telephone | 754-529-8265
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Fax | 754-529-8256
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ANGIE LISSET MENDOZA CASTILLO
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Credential |
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Telephone | 754-529-8265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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