Provider Demographics
NPI:1902011141
Name:PEDIATRIC HEALTH CENTER
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGERIO
Authorized Official - Middle Name:SERRANO
Authorized Official - Last Name:FAILLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-441-1144
Mailing Address - Street 1:5042 SW 173RD AVE.
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029
Mailing Address - Country:US
Mailing Address - Phone:954-441-1144
Mailing Address - Fax:
Practice Address - Street 1:1951 SW 172ND AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5593
Practice Address - Country:US
Practice Address - Phone:954-441-1144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 77924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty