Provider Demographics
NPI:1912615196
Name:ADVANCED CARE PEDIATRICS OF FLORIDA, LLC
Entity Type:Organization
Organization Name:ADVANCED CARE PEDIATRICS OF FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRISTOL
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIEN-DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:772-408-9588
Mailing Address - Street 1:3451 SW DARWIN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3873
Mailing Address - Country:US
Mailing Address - Phone:772-408-9588
Mailing Address - Fax:
Practice Address - Street 1:2401 FRIST BLVD STE 8910
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4839
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 OF FLORIDA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care