Healthcare Provider Details

I. General information

NPI: 1003123696
Provider Name (Legal Business Name): PED-E-CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 STATE ROAD 13 SUITE 104
FRUIT COVE FL
32259-3872
US

IV. Provider business mailing address

540 STATE ROAD 13 SUITE 104
FRUIT COVE FL
32259-3872
US

V. Phone/Fax

Practice location:
  • Phone: 904-814-8209
  • Fax:
Mailing address:
  • Phone: 904-814-8209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number60080992
License Number StateFL

VIII. Authorized Official

Name: MRS. JANE T PARK
Title or Position: DIRECTOR OF NURSING
Credential: RN
Phone: 904-608-4688