Provider Demographics
NPI:1396014536
Name:P.B. & R'S ENTERPRISES LLC
Entity Type:Organization
Organization Name:P.B. & R'S ENTERPRISES LLC
Other - Org Name:PRANA BLU MEDSPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMEBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETHZALI
Authorized Official - Middle Name:DEL C
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:ME
Authorized Official - Phone:727-330-7733
Mailing Address - Street 1:1200 S HIGHLAND AVE
Mailing Address - Street 2:SUITE 'B'
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-4334
Mailing Address - Country:US
Mailing Address - Phone:727-330-7733
Mailing Address - Fax:727-447-6008
Practice Address - Street 1:1200 S HIGHLAND AVE
Practice Address - Street 2:SUITE 'B'
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4334
Practice Address - Country:US
Practice Address - Phone:727-330-7733
Practice Address - Fax:727-447-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86204261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1851697056OtherPROVIDER NPI
FL278958500Medicaid
FLP00945853OtherPROVIDER PTAN
FL29118XMedicare PIN