MEDICARE: OUR PLACE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	1706AD870001	FL

General Provider Information

NPI Number	:	1235400938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR PLACE, LLC

Provider Business Mailing Address
First Line	:	460 S OCEAN DR
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-5125
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4699 N FEDERAL HWY
Second Line	:	SUITE 206A
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6510
Country	:	US
Telephone Number	:	888-976-2379
Fax Number	:	954-719-6762

Authorized Official
Title or Position	:	BILLING COORDINATOR
Name	:	JOSE FLORES
Credential	:
Telephone Number	:	754-201-2265

Provider Enumeration Date	:	01/26/2012
Last Update Date	:	12/04/2012

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Directions to “OUR PLACE, LLC ” Practice Location

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