Provider Demographics
NPI:1720370794
Name:PEDIATRIC LINKS,LLC
Entity Type:Organization
Organization Name:PEDIATRIC LINKS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:VIGILIA-MARAYA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:260-418-8051
Mailing Address - Street 1:7317 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6237
Mailing Address - Country:US
Mailing Address - Phone:260-418-8051
Mailing Address - Fax:260-489-3704
Practice Address - Street 1:7317 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6237
Practice Address - Country:US
Practice Address - Phone:260-418-8051
Practice Address - Fax:260-489-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPT05002613A2251P0200X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty