Provider Demographics
NPI:1396822862
Name:SAINT LUCIE PEDIATRICS INC
Entity Type:Organization
Organization Name:SAINT LUCIE PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ-TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-460-8235
Mailing Address - Street 1:2011 S 25TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4795
Mailing Address - Country:US
Mailing Address - Phone:772-460-8235
Mailing Address - Fax:
Practice Address - Street 1:2011 S 25TH ST STE 105
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4795
Practice Address - Country:US
Practice Address - Phone:772-460-8235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54098208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049315501Medicaid
FL049315501Medicaid