Healthcare Provider Details

I. General information

NPI: 1215434980
Provider Name (Legal Business Name): PEDIATRIC CENTER FOR EXCELLENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 BARTRAM PARK BLVD UNIT 209
JACKSONVILLE FL
32258-5233
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD UNIT 209
JACKSONVILLE FL
32258-5233
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-5437
  • Fax: 904-674-2313
Mailing address:
  • Phone: 904-224-5437
  • Fax: 904-674-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ASHRAF A AFFAN
Title or Position: OWNER
Credential: MD
Phone: 904-224-5437