Provider Demographics
NPI:1629524327
Name:PEDIATRICE CENTER FOR DEVELOPMENTAL EXCELLENCE, LLC
Entity Type:Organization
Organization Name:PEDIATRICE CENTER FOR DEVELOPMENTAL EXCELLENCE, LLC
Other - Org Name:PEDIATRIC BUILDING BLOCKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TREVENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-306-2065
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00821-0159
Mailing Address - Country:US
Mailing Address - Phone:340-473-7225
Mailing Address - Fax:
Practice Address - Street 1:79 ESTATE PETER'S REST
Practice Address - Street 2:SUITE 3.2
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-473-7225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI2351041B101YM0800X
VI12292080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty