Healthcare Provider Details

I. General information

NPI: 1467206524
Provider Name (Legal Business Name): PEDIATRIC NEUROCARE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 08/03/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PINE AVE N
OLDSMAR FL
34677-4629
US

IV. Provider business mailing address

PO BOX 320304
TAMPA FL
33679-2304
US

V. Phone/Fax

Practice location:
  • Phone: 480-652-2110
  • Fax:
Mailing address:
  • Phone: 813-553-4448
  • Fax: 813-525-9696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HIMALI JAYAKODY
Title or Position: PEDIATRIC NEUROLOGIST/ CEO
Credential: MD
Phone: 813-553-4448