Provider Demographics
NPI:1336495290
Name:POP'S HOUSE LLC
Entity type:Organization
Organization Name:POP'S HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-746-8232
Mailing Address - Street 1:4101 NE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6040
Mailing Address - Country:US
Mailing Address - Phone:954-746-8232
Mailing Address - Fax:954-746-8231
Practice Address - Street 1:4101 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-6040
Practice Address - Country:US
Practice Address - Phone:954-746-8232
Practice Address - Fax:954-746-8231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D2039731251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health