Provider Demographics
NPI:1114424280
Name:CHILDREN'S EXPRESS CARE CLINIC
Entity Type:Organization
Organization Name:CHILDREN'S EXPRESS CARE CLINIC
Other - Org Name:EXCEL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUWARNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TILAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-519-0008
Mailing Address - Street 1:10175 FORTUNE PARKWAY
Mailing Address - Street 2:SUITE 402
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6750
Mailing Address - Country:US
Mailing Address - Phone:904-519-0008
Mailing Address - Fax:904-379-7312
Practice Address - Street 1:10175 FORTUNE PARKWAY
Practice Address - Street 2:SUITE 402
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-519-0008
Practice Address - Fax:904-379-7312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S EXPRESS CARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-06
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty