Provider Demographics
NPI:1487004057
Name:BROKEN BUT RESTORED INC
Entity Type:Organization
Organization Name:BROKEN BUT RESTORED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:GENIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-244-7051
Mailing Address - Street 1:3179 W ATLANTIC BLVD STE 35
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-2565
Mailing Address - Country:US
Mailing Address - Phone:754-244-7051
Mailing Address - Fax:
Practice Address - Street 1:3179 W ATLANTIC BLVD STE 35
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-2565
Practice Address - Country:US
Practice Address - Phone:754-244-7051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No347C00000XTransportation ServicesPrivate Vehicle