Healthcare Provider Details

I. General information

NPI: 1902554041
Provider Name (Legal Business Name): THE PEACH PIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 S JOG RD
GREENACRES FL
33415-6101
US

IV. Provider business mailing address

9861 ROBINS NEST RD
BOCA RATON FL
33496-2144
US

V. Phone/Fax

Practice location:
  • Phone: 561-412-5577
  • Fax:
Mailing address:
  • Phone: 561-809-5461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTINE FRADILLADA
Title or Position: MANAGER
Credential:
Phone: 561-809-5461