=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164211934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2025
-----------------------------------------------------
Last Update Date | 07/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 998 N FEDERAL HWY
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33062-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-941-5731
-----------------------------------------------------
Fax | 954-941-2706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 947095
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30394-7095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP
-----------------------------------------------------
Name | MARCOS MESTRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-666-6511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------