=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114298601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDSWOODS PEDIATRICS CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2012
-----------------------------------------------------
Last Update Date | 01/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1936 LEE RD SUTIE 137
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-7229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-207-0623
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1177 KENWOOD AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ZULLY E AMBROISE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-398-6470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME98395
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------