=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316349905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL PEDIATRIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2014
-----------------------------------------------------
Last Update Date | 09/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E COMMERCIAL BLVD
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33334-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-351-0202
-----------------------------------------------------
Fax | 954-351-0201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E COMMERCIAL BLVD
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33334-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-351-0202
-----------------------------------------------------
Fax | 954-351-0201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JEANETTA FLOOD
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 954-351-0202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME0060159
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------