Provider Demographics
NPI:1568170447
Name:ADVANCED CARE PEDIATRICS OF FLORIDA, LLC
Entity Type:Organization
Organization Name:ADVANCED CARE PEDIATRICS OF FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRISTOL
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIEN-DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:772-321-1963
Mailing Address - Street 1:5670 S. WAHSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:772-321-1963
Mailing Address - Fax:
Practice Address - Street 1:5670 S. WAHSINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:772-321-1963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED CARE PEDIATRICS OF FLORIDA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care