MEDICARE: POP'S HOUSE, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1316362759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POP'S HOUSE, LLC

Provider Business Mailing Address
First Line	:	1661 E SAMPLE RD
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6279
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Provider Business Practice Location Address
First Line	:	1661 E SAMPLE RD
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33064-6279
Country	:	US
Telephone Number	:	954-746-8232
Fax Number	:	954-746-8231

Authorized Official
Title or Position	:	BILLING DEPARTMENT
Name	:	THERESA SMITH
Credential	:
Telephone Number	:	954-746-8232

Provider Enumeration Date	:	02/21/2014
Last Update Date	:	07/10/2014

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