Healthcare Provider Details

I. General information

NPI: 1184638819
Provider Name (Legal Business Name): PEDI PEC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15839 NW 2ND AVE
MIAMI FL
33169-6711
US

IV. Provider business mailing address

1450 NW 159TH ST
MIAMI FL
33169-5727
US

V. Phone/Fax

Practice location:
  • Phone: 305-948-5683
  • Fax:
Mailing address:
  • Phone: 305-623-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number60080975
License Number StateFL

VIII. Authorized Official

Name: MS. GRISELDA MILLER
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-623-1222