Healthcare Provider Details

I. General information

NPI: 1366699944
Provider Name (Legal Business Name): ABRAKIDABRA PEDIATRIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8391 OMAHA CIR
SPRING HILL FL
34606-5157
US

IV. Provider business mailing address

8391 OMAHA CIR
SPRING HILL FL
34606-5157
US

V. Phone/Fax

Practice location:
  • Phone: 352-688-8818
  • Fax: 877-487-5705
Mailing address:
  • Phone: 352-688-8818
  • Fax: 877-487-5705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9175935
License Number StateFL

VIII. Authorized Official

Name: MRS. HEATHER RIDDLE
Title or Position: PRESIDENT
Credential: A.R.N.P.
Phone: 352-688-8818