=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346081189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPACE COAST PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8045 SPYGLASS HILL RD STE 105
-----------------------------------------------------
City | VIERA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-467-1660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8045 SPYGLASS HILL RD STE 105
-----------------------------------------------------
City | VIERA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-269-1904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRICIAN
-----------------------------------------------------
Name | ARLEENE SEPULVEDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 772-269-1904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------