Provider Demographics
NPI:1174377568
Name:BRAVE KIDS PPEC LLC
Entity type:Organization
Organization Name:BRAVE KIDS PPEC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:LISSET
Authorized Official - Last Name:MENDOZA CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-529-8265
Mailing Address - Street 1:10168 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3938
Mailing Address - Country:US
Mailing Address - Phone:754-529-8265
Mailing Address - Fax:754-529-8256
Practice Address - Street 1:10168 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3938
Practice Address - Country:US
Practice Address - Phone:754-529-8265
Practice Address - Fax:754-529-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center