Basic Information
| Provider Information | |||||||||
| NPI: | 1487059713 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROWARD HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1726 SE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | 9545229357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1726 SE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | 9545229357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | HYDE | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9545224749 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | MH 12593 | FL | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.