Provider Demographics
NPI:1932495702
Name:THE KIDZ CLUB- ST PETE, LLC
Entity Type:Organization
Organization Name:THE KIDZ CLUB- ST PETE, LLC
Other - Org Name:THE KIDZ CLUB- ST. PETE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-210-5538
Mailing Address - Street 1:1101 HERR LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4301
Mailing Address - Country:US
Mailing Address - Phone:502-210-5538
Mailing Address - Fax:502-327-5098
Practice Address - Street 1:850 3RD AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4010
Practice Address - Country:US
Practice Address - Phone:727-821-5439
Practice Address - Fax:727-821-9459
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KY PPEC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-21
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL002082100227800000X
3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003967600Medicaid