Healthcare Provider Details

I. General information

NPI: 1023714359
Provider Name (Legal Business Name): NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 SHERIDAN ST STE 311
COOPER CITY FL
33026-1532
US

IV. Provider business mailing address

PO BOX 947095
ATLANTA GA
30394-7095
US

V. Phone/Fax

Practice location:
  • Phone: 954-435-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCOS MESTRE
Title or Position: SVP
Credential: MD
Phone: 305-666-6511