Healthcare Provider Details

I. General information

NPI: 1760803852
Provider Name (Legal Business Name): CSI-PEDIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 CASSAT AVE
JACKSONVILLE FL
32210-1634
US

IV. Provider business mailing address

15050 NW 79TH CT STE 201
MIAMI LAKES FL
33016-5810
US

V. Phone/Fax

Practice location:
  • Phone: 904-380-9099
  • Fax: 904-384-4885
Mailing address:
  • Phone: 865-229-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number60080998
License Number StateFL

VIII. Authorized Official

Name: DONNA LODATO
Title or Position: CEO
Credential: RN
Phone: 786-522-9600