Basic Information
| Provider Information | |||||||||
| NPI: | 1740773415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4575 SE DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349976826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1831 17TH CT N | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334606437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2018 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | BALLINGER | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8558326727 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.