Provider Demographics
NPI:1679590632
Name:KIDS TALK PLACE LLC
Entity Type:Organization
Organization Name:KIDS TALK PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-982-5798
Mailing Address - Street 1:4624 SUMMERDALE DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1368
Mailing Address - Country:US
Mailing Address - Phone:850-994-3456
Mailing Address - Fax:850-994-3476
Practice Address - Street 1:4624 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-982-5798
Practice Address - Fax:850-994-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889624100Medicaid
FL889624104Medicaid
Y90KNOtherBCBS
Y90KNOtherBCBS FL
FLT0925OtherBCBS NUMBER
FL889624101Medicaid
FL889624102Medicaid