Healthcare Provider Details

I. General information

NPI: 1396299244
Provider Name (Legal Business Name): NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE SUITE 304
MIAMI FL
33155
US

IV. Provider business mailing address

PO BOX 947095
ATLANTA GA
30394-7095
US

V. Phone/Fax

Practice location:
  • Phone: 786-624-5876
  • Fax: 786-624-2688
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCOS MESTRE
Title or Position: SVP
Credential:
Phone: 305-666-6511