Healthcare Provider Details

I. General information

NPI: 1740449511
Provider Name (Legal Business Name): SAINT LUCIE PEDIATRICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 N BROADWAY ST
FELLSMERE FL
32948-6601
US

IV. Provider business mailing address

2011 S 25TH ST 105
FORT PIERCE FL
34947-4753
US

V. Phone/Fax

Practice location:
  • Phone: 772-571-1533
  • Fax: 772-571-8081
Mailing address:
  • Phone: 772-571-1533
  • Fax: 772-571-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. LISA RODRIGUEZ
Title or Position: OFF MGR
Credential:
Phone: 772-571-1533