Healthcare Provider Details

I. General information

NPI: 1457805756
Provider Name (Legal Business Name): PEDIATRIC INNOVATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 BARTRAM PARK BLVD SUITE 209
JACKSONVILLE FL
32258-5212
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD SUITE 209
JACKSONVILLE FL
32258-5212
US

V. Phone/Fax

Practice location:
  • Phone: 904-616-2772
  • Fax: 904-674-2313
Mailing address:
  • Phone: 904-616-2772
  • Fax: 904-674-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME86016
License Number StateFL

VIII. Authorized Official

Name: ASHRAF AFFAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-616-2772