Provider Demographics
NPI:1740449511
Name:SAINT LUCIE PEDIATRICS INC.
Entity type:Organization
Organization Name:SAINT LUCIE PEDIATRICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-571-1533
Mailing Address - Street 1:2011 S 25TH ST
Mailing Address - Street 2:105
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4753
Mailing Address - Country:US
Mailing Address - Phone:772-571-1533
Mailing Address - Fax:772-571-8081
Practice Address - Street 1:32 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FELLSMERE
Practice Address - State:FL
Practice Address - Zip Code:32948-6601
Practice Address - Country:US
Practice Address - Phone:772-571-1533
Practice Address - Fax:772-571-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2634562001Medicaid