Provider Demographics
NPI:1376360578
Name:BRIGHTSIDE PEDIATRICS
Entity type:Organization
Organization Name:BRIGHTSIDE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-895-7337
Mailing Address - Street 1:1764 TREE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5723
Mailing Address - Country:US
Mailing Address - Phone:904-895-7337
Mailing Address - Fax:904-925-1365
Practice Address - Street 1:1764 TREE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5723
Practice Address - Country:US
Practice Address - Phone:904-895-7337
Practice Address - Fax:904-925-1365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care