Provider Demographics
NPI:1326251596
Name:SUNLIFE PEDIATRIC NETWORK INC
Entity Type:Organization
Organization Name:SUNLIFE PEDIATRIC NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-889-4029
Mailing Address - Street 1:10051 PINES BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6187
Mailing Address - Country:US
Mailing Address - Phone:954-743-2996
Mailing Address - Fax:954-589-2131
Practice Address - Street 1:10051 PINES BLVD STE A
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6187
Practice Address - Country:US
Practice Address - Phone:954-743-2996
Practice Address - Fax:954-558-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 689332080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378537800Medicaid