Healthcare Provider Details

I. General information

NPI: 1194033753
Provider Name (Legal Business Name): PINNACLES PEDS CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 PINNACLES DR SUITE 100
PALM COAST FL
32164-2596
US

IV. Provider business mailing address

3 COLLEGE CT
PALM COAST FL
32137-9034
US

V. Phone/Fax

Practice location:
  • Phone: 386-313-1963
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 97678
License Number StateFL

VIII. Authorized Official

Name: DR. VINCENT G VERDEFLOR
Title or Position: DIRECTOR
Credential: M.D.
Phone: 386-597-2298