Provider Demographics
NPI:1558874065
Name:SEA RANCH GROUP, INC.
Entity Type:Organization
Organization Name:SEA RANCH GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BRIGIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FENELON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-451-3010
Mailing Address - Street 1:4701 N FEDERAL HWY STE A39
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4701 N FEDERAL HWY STE A39
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4608
Practice Address - Country:US
Practice Address - Phone:954-651-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051855700Medicaid