MEDICARE: SEA RANCH GROUP, 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	207X00000X	Orthopaedic Surgery Physician

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	:	1558874065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA RANCH GROUP, INC.

Provider Business Mailing Address
First Line	:	4701 N FEDERAL HWY STE A39
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 N FEDERAL HWY STE A39
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4608
Country	:	US
Telephone Number	:	954-651-9771
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS OPERATIONS
Name	:	BRIGIDA FENELON
Credential	:
Telephone Number	:	954-451-3010

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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Directions to “SEA RANCH GROUP, INC. ” Practice Location

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