Provider Demographics
NPI:1619186087
Name:PEDIATRIC CARE CENTER LLC
Entity Type:Organization
Organization Name:PEDIATRIC CARE CENTER LLC
Other - Org Name:PEDIATRIC CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE COORDIATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:340-719-9039
Mailing Address - Street 1:PO BOX 7462
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00823-7462
Mailing Address - Country:US
Mailing Address - Phone:340-719-0681
Mailing Address - Fax:340-719-9023
Practice Address - Street 1:4504 ESTATE DIAMOND RUBY
Practice Address - Street 2:SUITE #3 FLAGSTAR PROFESSIONAL BUILDING
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-719-0681
Practice Address - Fax:340-719-9023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty