1568038511 NPI number — ANGEL KIDS PA

Table of content: (NPI 1568038511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568038511 NPI number — ANGEL KIDS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGEL KIDS PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568038511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13241 BARTRAM PARK BLVD UNIT 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32258-5233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-242-4220
Provider Business Mailing Address Fax Number:
904-674-2313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8225 NORMANDY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32221-6650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-786-9600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GHANDOUR
Authorized Official First Name:
AZZA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING/CREDENTIALING MANAGER
Authorized Official Telephone Number:
904-242-4220

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)