Healthcare Provider Details

I. General information

NPI: 1013577246
Provider Name (Legal Business Name): NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 11/06/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 W 16TH AVE STE 60
HIALEAH FL
33012-7194
US

IV. Provider business mailing address

3100 SW 62ND AVE
MIAMI FL
33155-3009
US

V. Phone/Fax

Practice location:
  • Phone: 305-823-0721
  • Fax: 305-823-2011
Mailing address:
  • Phone: 305-643-0133
  • Fax: 305-643-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA M GABER
Title or Position: PROVIDER RELATIONS SPECIALIST
Credential:
Phone: 786-624-5747