Provider Demographics
NPI:1659531309
Name:PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, INC
Entity Type:Organization
Organization Name:PRISON REHABILITATIVE INDUSTRIES DIVERSIFIED ENTERPRISES, INC
Other - Org Name:P.R.I.D.E BROWARD OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:RADANOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-556-3370
Mailing Address - Street 1:12425 28TH ST N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1844
Mailing Address - Country:US
Mailing Address - Phone:727-572-1987
Mailing Address - Fax:727-570-3378
Practice Address - Street 1:20421 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33332-2300
Practice Address - Country:US
Practice Address - Phone:800-523-1766
Practice Address - Fax:813-890-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS. 2220332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086571100Medicaid