=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437226776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH BROWARD PAIN & REHAB CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6049 MIRAMAR PKWY
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-983-4410
-----------------------------------------------------
Fax | 954-983-8354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6049 MIRAMAR PKWY
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-9337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-983-4410
-----------------------------------------------------
Fax | 954-983-8354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. ERIC R. MILLER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 954-983-4410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH5357
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------