Provider Demographics
NPI:1356652135
Name:CHILDRENS CENTER FOR GASTROENTEROLOGY & NUTRITION, PA
Entity Type:Organization
Organization Name:CHILDRENS CENTER FOR GASTROENTEROLOGY & NUTRITION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:TANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-967-9400
Mailing Address - Street 1:1150 N 35TH AVE
Mailing Address - Street 2:SUITE 545
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5424
Mailing Address - Country:US
Mailing Address - Phone:954-967-9400
Mailing Address - Fax:954-967-9551
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:SUITE 545
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5424
Practice Address - Country:US
Practice Address - Phone:954-967-9400
Practice Address - Fax:954-967-9551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty