Healthcare Provider Details

I. General information

NPI: 1134175060
Provider Name (Legal Business Name): KINDCARE PEDIATRIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 MONROE ST
PASSAIC NJ
07055-5209
US

IV. Provider business mailing address

PO BOX 667
BELLEVILLE NJ
07109-0667
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-8688
  • Fax:
Mailing address:
  • Phone: 973-574-8688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA077362
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0039586
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. YOCASTA FERNANDEZ
Title or Position: OWNER
Credential: MD
Phone: 973-574-8688