Provider Demographics
NPI:1518465053
Name:LITTLE ANGELS PEDIATRIC EXTENDED CARE LLC
Entity Type:Organization
Organization Name:LITTLE ANGELS PEDIATRIC EXTENDED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-755-3127
Mailing Address - Street 1:222 NEIGHBORHOOD MARKET RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3525
Mailing Address - Country:US
Mailing Address - Phone:407-403-5822
Mailing Address - Fax:
Practice Address - Street 1:222 NEIGHBORHOOD MARKET RD STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3525
Practice Address - Country:US
Practice Address - Phone:407-403-5822
Practice Address - Fax:407-403-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024820200Medicaid