Provider Demographics
NPI:1962628289
Name:CHILDRENS DIAGNOSTIC & TREATMENT CENTER INC
Entity Type:Organization
Organization Name:CHILDRENS DIAGNOSTIC & TREATMENT CENTER INC
Other - Org Name:TCM GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON RANDAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-728-1060
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-728-8080
Mailing Address - Fax:
Practice Address - Street 1:1401 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2619
Practice Address - Country:US
Practice Address - Phone:954-728-8080
Practice Address - Fax:954-779-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055049300Medicaid
FL34478OtherBCBS
FL34478Medicare PIN