Healthcare Provider Details

I. General information

NPI: 1265862411
Provider Name (Legal Business Name): SUNSHINE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2013
Last Update Date: 11/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S TREE GARDEN DR
ST AUGUSTINE FL
32086-5234
US

IV. Provider business mailing address

601 S TREE GARDEN DR
ST AUGUSTINE FL
32086-5234
US

V. Phone/Fax

Practice location:
  • Phone: 904-669-4285
  • Fax: 904-797-6064
Mailing address:
  • Phone: 904-669-4285
  • Fax: 904-797-6064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 20437
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 9943
License Number StateFL

VIII. Authorized Official

Name: KIMBERLY MCKINNEY
Title or Position: OWNER
Credential: OT PT
Phone: 904-669-4285