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General NPI Number Information
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NPI Number | 1396250098
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Entity Type | Organization
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Legal Business Name | ADVANCED KID'S CARE
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Dates
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Enumeration Date | 12/05/2017
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Last Update Date | 12/05/2017
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Provider Practice Location Address
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Address Line | 98 TERRA MANGO LOOP UNIT 12
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City | ORLANDO
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State | FL
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Zip | 32835
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Country | US
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Telephone | 419-819-7137
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Fax |
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Provider Business Mailing Address
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Address Line | 5049 LATROBE DR
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City | WINDERMERE
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State | FL
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Zip | 34786-8914
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Country | US
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Telephone | 419-819-6804
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. BERNADETTE ANTONYRAJAH
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Credential | MD
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Telephone | 419-819-7137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME113681
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License Number State | FL
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