MEDICARE: CHIKOS PEDIATRIC SERVICES

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	261QM1300X	Multi-Specialty Clinic/Center	253095	FL

General Provider Information

NPI Number	:	1568713857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIKOS PEDIATRIC SERVICES

Provider Business Mailing Address
First Line	:	2702 W WATERS AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1837
Country	:	US
Telephone Number	:	813-933-3350
Fax Number	:	813-933-3334

Provider Business Practice Location Address
First Line	:	2702 W WATERS AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1837
Country	:	US
Telephone Number	:	813-933-3350
Fax Number	:	813-933-3334

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MRS. MIRIAM GONZALEZ
Credential	:
Telephone Number	:	813-933-3350

Provider Enumeration Date	:	09/26/2012
Last Update Date	:	09/26/2012

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