Healthcare Provider Details

I. General information

NPI: 1386210367
Provider Name (Legal Business Name): ANGEL KIDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 STATE ROAD 13
ST JOHNS FL
32259-3857
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD UNIT 209
JACKSONVILLE FL
32258-5233
US

V. Phone/Fax

Practice location:
  • Phone: 904-242-4220
  • Fax:
Mailing address:
  • Phone: 904-242-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: AZZA GHANDOUR
Title or Position: BILLING/CREDENTIALING MANAGER
Credential:
Phone: 904-242-4220