Healthcare Provider Details

I. General information

NPI: 1902011141
Provider Name (Legal Business Name): PEDIATRIC HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 SW 172ND AVE
MIRAMAR FL
33029-5593
US

IV. Provider business mailing address

5042 SW 173RD AVE.
MIRAMAR FL
33029
US

V. Phone/Fax

Practice location:
  • Phone: 954-441-1144
  • Fax:
Mailing address:
  • Phone: 954-441-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 77924
License Number StateFL

VIII. Authorized Official

Name: ROGERIO SERRANO FAILLACE
Title or Position: PRESIDENT
Credential: M.D
Phone: 954-441-1144