Healthcare Provider Details

I. General information

NPI: 1356652135
Provider Name (Legal Business Name): CHILDRENS CENTER FOR GASTROENTEROLOGY & NUTRITION, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE SUITE 545
HOLLYWOOD FL
33021-5424
US

IV. Provider business mailing address

1150 N 35TH AVE SUITE 545
HOLLYWOOD FL
33021-5424
US

V. Phone/Fax

Practice location:
  • Phone: 954-967-9400
  • Fax: 954-967-9551
Mailing address:
  • Phone: 954-967-9400
  • Fax: 954-967-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MARIO ENRIQUE TANO
Title or Position: PRESIDENT
Credential: MD
Phone: 954-967-9400