Provider Demographics
NPI:1811927262
Name:PHOENIX CLINIC INC OF BROWARD
Entity type:Organization
Organization Name:PHOENIX CLINIC INC OF BROWARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-891-3439
Mailing Address - Street 1:2212 SW 60TH TERRACE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023
Mailing Address - Country:US
Mailing Address - Phone:954-491-2133
Mailing Address - Fax:954-491-2344
Practice Address - Street 1:2212 SW 60TH TERRACE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023
Practice Address - Country:US
Practice Address - Phone:954-491-2133
Practice Address - Fax:954-491-2344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1006AD354501261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)