Healthcare Provider Details

I. General information

NPI: 1609965441
Provider Name (Legal Business Name): PEDIATRIC HEALTH CARE ALLIANCE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/31/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 BROOKER CREEK BLVD STE 215
OLDSMAR FL
34677-2937
US

IV. Provider business mailing address

720 BROOKER CREEK BLVD STE 215
OLDSMAR FL
34677-2937
US

V. Phone/Fax

Practice location:
  • Phone: 813-854-2003
  • Fax: 813-436-5378
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-436-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEBRA S. GONZALEZ
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 813-854-2003