Provider Demographics
NPI:1265504773
Name:CARMEN PEDIATRIC CARE CENTER, INC
Entity Type:Organization
Organization Name:CARMEN PEDIATRIC CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEISS BOGACZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:954-731-4474
Mailing Address - Street 1:2589 NORTH STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313
Mailing Address - Country:US
Mailing Address - Phone:954-731-4474
Mailing Address - Fax:
Practice Address - Street 1:2589 NORTH STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-731-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60080978261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL830092500Medicaid
FL240022700Medicaid