Provider Demographics
NPI:1083719256
Name:PEDIATRIC CARE CENTER, P.L.L.C.
Entity Type:Organization
Organization Name:PEDIATRIC CARE CENTER, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-762-9595
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-0726
Mailing Address - Country:US
Mailing Address - Phone:228-762-9595
Mailing Address - Fax:228-762-9494
Practice Address - Street 1:4105 HOSPITAL ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5312
Practice Address - Country:US
Practice Address - Phone:228-762-9595
Practice Address - Fax:228-762-9494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS009016223Medicaid
MS09016223Medicaid