=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083719256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC CARE CENTER, P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4105 HOSPITAL ST SUITE 104
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39581-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-762-9595
-----------------------------------------------------
Fax | 228-762-9494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 726
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39568-0726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-762-9595
-----------------------------------------------------
Fax | 228-762-9494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. NIKKI HOFFMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-762-9595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------