Provider Demographics
NPI:1720531650
Name:HOMETOWN PEDIATRICS LLC
Entity Type:Organization
Organization Name:HOMETOWN PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OF MANAGING COMPANY
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENICHINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-674-8905
Mailing Address - Street 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8905
Mailing Address - Fax:352-674-8919
Practice Address - Street 1:1400 N US HIGHWAY 441
Practice Address - Street 2:SUITE 522
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-8975
Practice Address - Country:US
Practice Address - Phone:352-674-8905
Practice Address - Fax:352-674-8919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty