Provider Demographics
NPI:1154081123
Name:NIGHT LITE PEDIATRIC CENTER, LLC
Entity Type:Organization
Organization Name:NIGHT LITE PEDIATRIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-243-3839
Mailing Address - Street 1:5900 S JOHN YOUNG PKWY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-3716
Mailing Address - Country:US
Mailing Address - Phone:407-398-6470
Mailing Address - Fax:
Practice Address - Street 1:145 PALM BAY RD NE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8601
Practice Address - Country:US
Practice Address - Phone:321-608-3595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113228409Medicaid