Provider Demographics
NPI:1326353269
Name:MEDEBRA INC
Entity Type:Organization
Organization Name:MEDEBRA INC
Other - Org Name:MEDEBRA INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:PAUCEK
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-763-9479
Mailing Address - Street 1:2530 OKEECHOBEE LN
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4624
Mailing Address - Country:US
Mailing Address - Phone:954-763-9479
Mailing Address - Fax:954-712-2289
Practice Address - Street 1:2530 OKEECHOBEE LN
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-4624
Practice Address - Country:US
Practice Address - Phone:954-763-9479
Practice Address - Fax:954-712-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization