Provider Demographics
NPI:1558743666
Name:ST JUDE PROFESSIONAL CARE INC
Entity Type:Organization
Organization Name:ST JUDE PROFESSIONAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICODEMO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:786-663-6394
Mailing Address - Street 1:9806 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6141
Mailing Address - Country:US
Mailing Address - Phone:786-663-6394
Mailing Address - Fax:954-367-5246
Practice Address - Street 1:9806 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6141
Practice Address - Country:US
Practice Address - Phone:786-663-6394
Practice Address - Fax:954-367-5246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25877208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty