1629524327 NPI number — PEDIATRICE CENTER FOR DEVELOPMENTAL EXCELLENCE, LLC

Table of content: (NPI 1629524327)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629524327 NPI number — PEDIATRICE CENTER FOR DEVELOPMENTAL EXCELLENCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:
PEDIATRICE CENTER FOR DEVELOPMENTAL EXCELLENCE, LLC

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:
PEDIATRIC BUILDING BLOCKS

Provider Other Organization Name Type Code:
3

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:
1629524327

Entity Type Code:
Organization

Replacement NPI:

Last Update Date:
09/12/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 159

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
CHRISTIANSTED

Provider Business Mailing Address State Name:
VI

Provider Business Mailing Address Postal Code:
00821-0159

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
340-473-7225

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 ESTATE PETER'S REST

Provider Second Line Business Practice Location Address:
SUITE 3.2

Provider Business Practice Location Address City Name:
CHRISTIANSTED

Provider Business Practice Location Address State Name:
VI

Provider Business Practice Location Address Postal Code:
00820

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
340-473-7225

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
09/01/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE

Authorized Official First Name:
TREVENA

Authorized Official Middle Name:

Authorized Official Title or Position:
MEMBER

Authorized Official Telephone Number:
617-306-2065

Provider Taxonomy Codes

Taxonomy code: 101YM0800X , with the licence number: 2351041B , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 2080P0006X , with the licence number: 1229 , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .