Provider Demographics
NPI:1174199137
Name:ANGEL KIDS PA
Entity Type:Organization
Organization Name:ANGEL KIDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AZZA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANDOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-242-4220
Mailing Address - Street 1:13241 BARTRAM PARK BLVD UNIT 209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5233
Mailing Address - Country:US
Mailing Address - Phone:904-242-4220
Mailing Address - Fax:
Practice Address - Street 1:13443 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3131
Practice Address - Country:US
Practice Address - Phone:904-242-4220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty