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General NPI Number Information
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NPI Number | 1659531309
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Entity Type | Organization
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Legal Business Name | PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, INC
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Dates
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Enumeration Date | 06/16/2008
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 20421 SHERIDAN ST
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City | FT LAUDERDALE
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State | FL
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Zip | 33332-2300
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Country | US
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Telephone | 800-523-1766
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Fax | 813-890-2103
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Provider Business Mailing Address
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Address Line | 12425 28TH ST N SUITE 300
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City | ST PETERSBURG
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State | FL
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Zip | 33716-1844
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Country | US
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Telephone | 727-572-1987
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Fax | 727-570-3378
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. PETER RADANOVICH
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Credential |
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Telephone | 727-556-3370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | S. 2220
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License Number State | OH
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