Provider Demographics
NPI:1659872760
Name:CSI-PEDIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:CSI-PEDIATRIC SERVICES, LLC
Other - Org Name:SPARK PEDIATRICS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LODATO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:786-522-9600
Mailing Address - Street 1:15050 NW 79TH CT STE 201
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5810
Mailing Address - Country:US
Mailing Address - Phone:786-522-9600
Mailing Address - Fax:
Practice Address - Street 1:10060 W MCNAB RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1894
Practice Address - Country:US
Practice Address - Phone:954-947-3100
Practice Address - Fax:954-933-7576
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-23
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101530900Medicaid