Provider Demographics
NPI:1942917208
Name:ADVANCED CARE PEDIATRICS, INC.
Entity Type:Organization
Organization Name:ADVANCED CARE PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CRISTOL
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIEN-DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-408-9588
Mailing Address - Street 1:5670 S. WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5670 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:32780-3495
Practice Address - Country:US
Practice Address - Phone:772-408-9588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED CARE PEDIATRICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care