Provider Demographics
NPI:1578908968
Name:BIGBEND PEDIATRIC CARE, LLC
Entity Type:Organization
Organization Name:BIGBEND PEDIATRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-672-6092
Mailing Address - Street 1:13131 KINGS LAKE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3959
Mailing Address - Country:US
Mailing Address - Phone:813-672-6092
Mailing Address - Fax:813-677-1892
Practice Address - Street 1:13131 KINGS LAKE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3959
Practice Address - Country:US
Practice Address - Phone:813-672-6092
Practice Address - Fax:813-677-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
FLME98642302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110510700Medicaid