MEDICARE: COMMUNITY BASED CONNECTIONS, INC.

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255004057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY BASED CONNECTIONS, INC.

Provider Business Mailing Address
First Line	:	1021 NW 6TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-8055
Country	:	US
Telephone Number	:	954-908-5249
Fax Number	:	954-524-2119

Provider Business Practice Location Address
First Line	:	1021 NW 6TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-8055
Country	:	US
Telephone Number	:	954-908-5249
Fax Number	:	954-524-2119

Authorized Official
Title or Position	:	CEO
Name	:	MIKELANGE OLBEL
Credential	:	MS
Telephone Number	:	954-908-5249

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	07/28/2021

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