1023489630 NPI number — BEE WELL PEDIATRICS

Table of content: (NPI 1023489630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023489630 NPI number — BEE WELL PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEE WELL PEDIATRICS
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:
1023489630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 880313
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34988-0313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-873-7114
Provider Business Mailing Address Fax Number:
772-873-7115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10521 SW VILLAGE CENTER DR
Provider Second Line Business Practice Location Address:
101-A
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34987-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-873-7114
Provider Business Practice Location Address Fax Number:
772-873-7115
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ESPINOZA
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
772-236-9860

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME93497 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 281166900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020370100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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