Provider Demographics
NPI:1255328431
Name:SOUTH BROWARD BRACE & SURGICAL SUPPORTS INC
Entity Type:Organization
Organization Name:SOUTH BROWARD BRACE & SURGICAL SUPPORTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETTI
Authorized Official - Suffix:
Authorized Official - Credentials:LO
Authorized Official - Phone:954-922-9061
Mailing Address - Street 1:1920 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:STE 702
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4722
Mailing Address - Country:US
Mailing Address - Phone:954-922-9061
Mailing Address - Fax:954-458-8611
Practice Address - Street 1:1920 E HALLANDALE BEACH BLVD
Practice Address - Street 2:STE 702
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4722
Practice Address - Country:US
Practice Address - Phone:954-922-9061
Practice Address - Fax:954-458-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT38335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0135410001Medicare ID - Type Unspecified