MEDICARE: PB OUTPATIENT SERVICES FLORIDA, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
3	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1255818639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PB OUTPATIENT SERVICES FLORIDA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 207807
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7807
Country	:	US
Telephone Number	:	561-337-2600
Fax Number	:	847-329-4900

Provider Business Practice Location Address
First Line	:	112 N OAK ST STE 109
Second Line	:
City	:	LANTANA
State	:	FL
Zip	:	33462-3260
Country	:	US
Telephone Number	:	615-567-7252
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	ROBERT S. WAGGENER
Credential	:
Telephone Number	:	615-567-7253

Provider Enumeration Date	:	07/27/2018
Last Update Date	:	12/27/2021

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