MEDICARE: OCEAN BREEZE DETOX 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		FL

General Provider Information

NPI Number	:	1407301096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN BREEZE DETOX LLC

Provider Business Mailing Address
First Line	:	PO BOX 714416
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45271-4416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8401 SOUTH PALM DRIVE
Second Line	:	BUILDING #60
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-4563
Country	:	US
Telephone Number	:	954-842-7575
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MICHAEL BORKOWSKI
Credential	:
Telephone Number	:	954-487-1224

Provider Enumeration Date	:	08/24/2016
Last Update Date	:	08/25/2021

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