Provider Demographics
NPI:1790033256
Name:PRESCRIBED PEDIATRIC EXTENDED CARE INC.
Entity Type:Organization
Organization Name:PRESCRIBED PEDIATRIC EXTENDED CARE INC.
Other - Org Name:PEDIATRIC HEALTH CHOICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BEHAVIOR SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:RHIANNON
Authorized Official - Last Name:WACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-804-4748
Mailing Address - Street 1:4144 N ARMENIA AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6434
Mailing Address - Country:US
Mailing Address - Phone:813-872-8521
Mailing Address - Fax:813-200-3707
Practice Address - Street 1:4144 N ARMENIA AVE STE 350
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6434
Practice Address - Country:US
Practice Address - Phone:813-872-8521
Practice Address - Fax:813-200-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health