1760803852 NPI number — CSI-PEDIATRIC SERVICES, LLC

Table of content: (NPI 1760803852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760803852 NPI number — CSI-PEDIATRIC SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CSI-PEDIATRIC SERVICES, 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:
Provider Other Organization Name Type Code:
6
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:
1760803852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15050 NW 79TH CT STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33016-5810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-229-6007
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1855 CASSAT AVE
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:
32210-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-380-9099
Provider Business Practice Location Address Fax Number:
904-384-4885
Provider Enumeration Date:
12/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LODATO
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
786-522-9600

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  60080998 , 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: 024128100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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