Healthcare Provider Details

I. General information

NPI: 1164631511
Provider Name (Legal Business Name): CARING HEARTS PEDIATRIC EXTENDED CARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MEDCREST DR
CRESTVIEW FL
32536
US

IV. Provider business mailing address

380 MEDCREST DR
CRESTVIEW FL
32536
US

V. Phone/Fax

Practice location:
  • Phone: 850-475-0555
  • Fax: 850-475-0650
Mailing address:
  • Phone: 850-475-0555
  • Fax: 850-475-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number60080985
License Number StateFL

VIII. Authorized Official

Name: JOSEPH HARRELSON
Title or Position: CEO
Credential:
Phone: 850-475-0555