Provider Demographics
NPI:1194091470
Name:PBAG, LLC
Entity type:Organization
Organization Name:PBAG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-370-1111
Mailing Address - Street 1:PO BOX 6455
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FLORIDA
Mailing Address - Zip Code:33405
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 CLINTMOORE ROAD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496
Practice Address - Country:US
Practice Address - Phone:561-544-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty