Healthcare Provider Details

I. General information

NPI: 1619186087
Provider Name (Legal Business Name): PEDIATRIC CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 ESTATE DIAMOND RUBY SUITE #3 FLAGSTAR PROFESSIONAL BUILDING
CHRISTIANSTED VI
00820
US

IV. Provider business mailing address

PO BOX 7462
CHRISTIANSTED VI
00823-7462
US

V. Phone/Fax

Practice location:
  • Phone: 340-719-0681
  • Fax: 340-719-9023
Mailing address:
  • Phone: 340-719-0681
  • Fax: 340-719-9023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1103
License Number StateVI

VIII. Authorized Official

Name: MRS. SHARON RICKETTS
Title or Position: PRACTICE COORDIATOR
Credential:
Phone: 340-719-9039