=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134446107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URQUIZA PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2010
-----------------------------------------------------
Last Update Date | 04/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1545 LAKELAND HILLS BLVD
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-686-5943
-----------------------------------------------------
Fax | 863-686-4013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1545 LAKELAND HILLS BLVD
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-686-5943
-----------------------------------------------------
Fax | 863-686-4013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING AGENT
-----------------------------------------------------
Name | NIKKI MORRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-534-3259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME14800
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------