Healthcare Provider Details

I. General information

NPI: 1174124275
Provider Name (Legal Business Name): SUPERKIDS EXTENDED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NE 168TH ST
NORTH MIAMI BEACH FL
33162-3411
US

IV. Provider business mailing address

125 NE 168TH ST
NORTH MIAMI BEACH FL
33162-3411
US

V. Phone/Fax

Practice location:
  • Phone: 305-244-4133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NYAH LOPEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 305-244-4133