Provider Demographics
NPI:1164631511
Name:CARING HEARTS PEDIATRIC EXTENDED CARE CENTER, INC
Entity Type:Organization
Organization Name:CARING HEARTS PEDIATRIC EXTENDED CARE CENTER, INC
Other - Org Name:CARING HEARTS PEDIATRIC EXTENDED CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-475-0555
Mailing Address - Street 1:380 MEDCREST DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536
Mailing Address - Country:US
Mailing Address - Phone:850-475-0555
Mailing Address - Fax:850-475-0650
Practice Address - Street 1:380 MEDCREST DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536
Practice Address - Country:US
Practice Address - Phone:850-475-0555
Practice Address - Fax:850-475-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60080985261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113402700Medicaid