Healthcare Provider Details

I. General information

NPI: 1407974579
Provider Name (Legal Business Name): NIGHT LITE PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 S JOHN YOUNG PKWY
ORLANDO FL
32839-3716
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 407-398-6470
  • Fax: 407-894-6872
Mailing address:
  • Phone: 516-207-7936
  • Fax: 516-207-7936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0061521
License Number StateFL

VIII. Authorized Official

Name: DANIELLE MARIE LOPEZ
Title or Position: MANAGER CREDENTIALING/ENROLLMENT
Credential:
Phone: 516-207-7936