Provider Demographics
NPI:1124036819
Name:KIDS HEALTH PLACE
Entity Type:Organization
Organization Name:KIDS HEALTH PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-467-0961
Mailing Address - Street 1:2900 W MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-4955
Mailing Address - Country:US
Mailing Address - Phone:772-467-0961
Mailing Address - Fax:772-467-6683
Practice Address - Street 1:2900 W MIDWAY RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4955
Practice Address - Country:US
Practice Address - Phone:772-467-0961
Practice Address - Fax:772-467-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty