Provider Demographics
NPI:1518432038
Name:CAPERNAUM MEDICAL CENTER FOR KIDS PLLC
Entity Type:Organization
Organization Name:CAPERNAUM MEDICAL CENTER FOR KIDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ROBERTO
Authorized Official - Last Name:VERNIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-232-4323
Mailing Address - Street 1:5129 S LAKELAND DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2599
Mailing Address - Country:US
Mailing Address - Phone:863-232-4323
Mailing Address - Fax:863-337-5728
Practice Address - Street 1:5129 S. LAKLAND DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2599
Practice Address - Country:US
Practice Address - Phone:863-232-4323
Practice Address - Fax:863-337-5728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019415800Medicaid