Provider Demographics
NPI:1689758328
Name:PEDIATRIC ALTERNATIVE TREATMENT CARE HOUSING AND EVALUATION SERVICES I
Entity Type:Organization
Organization Name:PEDIATRIC ALTERNATIVE TREATMENT CARE HOUSING AND EVALUATION SERVICES I
Other - Org Name:PATCHES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AZONA
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN
Authorized Official - Phone:305-242-8122
Mailing Address - Street 1:335 S KROME AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-4906
Mailing Address - Country:US
Mailing Address - Phone:305-242-8122
Mailing Address - Fax:305-242-8837
Practice Address - Street 1:335 S KROME AVE
Practice Address - Street 2:SUITE 104-107
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-4906
Practice Address - Country:US
Practice Address - Phone:305-242-8122
Practice Address - Fax:305-242-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL240023500Medicaid