Healthcare Provider Details

I. General information

NPI: 1346081189
Provider Name (Legal Business Name): SPACE COAST PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 SPYGLASS HILL RD STE 105
VIERA FL
32940-8567
US

IV. Provider business mailing address

8045 SPYGLASS HILL RD STE 105
VIERA FL
32940-8567
US

V. Phone/Fax

Practice location:
  • Phone: 321-467-1660
  • Fax:
Mailing address:
  • Phone: 772-269-1904
  • 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: ARLEENE SEPULVEDA
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 772-269-1904