Healthcare Provider Details

I. General information

NPI: 1124036819
Provider Name (Legal Business Name): KIDS HEALTH PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W MIDWAY RD
FORT PIERCE FL
34981-4955
US

IV. Provider business mailing address

2900 W MIDWAY RD
FORT PIERCE FL
34981-4955
US

V. Phone/Fax

Practice location:
  • Phone: 772-467-0961
  • Fax: 772-467-6683
Mailing address:
  • Phone: 772-467-0961
  • Fax: 772-467-6683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DAVID GARTH WALTERS
Title or Position: PRESIDENT
Credential: MD
Phone: 772-467-0961