MEDICARE: SHINING STARS PEDIATRIC EXTENDED CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM3000X	Medically Fragile Infants and Children Day Care

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326647363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING STARS PEDIATRIC EXTENDED CARE, LLC

Provider Business Mailing Address
First Line	:	6840 SW 14TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33144-5531
Country	:	US
Telephone Number	:	305-458-8688
Fax Number	:

Provider Business Practice Location Address
First Line	:	5201 RAVENSWOOD RD STE 110
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-6004
Country	:	US
Telephone Number	:	786-496-0287
Fax Number	:

Authorized Official
Title or Position	:	TITLE MANAGER
Name	:	MRS. NATALIE MARTINEZ
Credential	:
Telephone Number	:	305-458-8688

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	11/08/2022

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