Provider Demographics
NPI:1003123696
Name:PED-E-CARE
Entity Type:Organization
Organization Name:PED-E-CARE
Other - Org Name:PARC PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-608-4688
Mailing Address - Street 1:540 STATE ROAD 13
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FRUIT COVE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3872
Mailing Address - Country:US
Mailing Address - Phone:904-814-8209
Mailing Address - Fax:
Practice Address - Street 1:540 STATE ROAD 13
Practice Address - Street 2:SUITE 104
Practice Address - City:FRUIT COVE
Practice Address - State:FL
Practice Address - Zip Code:32259-3872
Practice Address - Country:US
Practice Address - Phone:904-814-8209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60080992251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60080992OtherPPEC LICENSE NUMBER