=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245951136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICKLAUS CHILDREN'S PEDIATRIC SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2022
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11190 HEALTH PARK BLVD
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-5729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-624-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------