Provider Demographics
NPI:1255818639
Name:PB OUTPATIENT SERVICES FLORIDA, LLC
Entity type:Organization
Organization Name:PB OUTPATIENT SERVICES FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-567-7253
Mailing Address - Street 1:PO BOX 207807
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7807
Mailing Address - Country:US
Mailing Address - Phone:561-337-2600
Mailing Address - Fax:847-329-4900
Practice Address - Street 1:112 N OAK ST STE 109
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-3260
Practice Address - Country:US
Practice Address - Phone:615-567-7252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder