Healthcare Provider Details

I. General information

NPI: 1467085902
Provider Name (Legal Business Name): PEDIATRIC RHEUMATOLOGY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12591 SORRENTO RD STE A
PENSACOLA FL
32507-8754
US

IV. Provider business mailing address

29939 ONO BLVD
ORANGE BEACH AL
36561-3634
US

V. Phone/Fax

Practice location:
  • Phone: 850-262-8645
  • Fax: 850-262-8647
Mailing address:
  • Phone: 501-231-4367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM KUETTEL
Title or Position: CEO
Credential:
Phone: 850-262-8645