=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568713857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIKOS PEDIATRIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2012
-----------------------------------------------------
Last Update Date | 09/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2702 W WATERS AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-933-3350
-----------------------------------------------------
Fax | 813-933-3334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2702 W WATERS AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-1837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-933-3350
-----------------------------------------------------
Fax | 813-933-3334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MRS. MIRIAM GONZALEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-933-3350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 253095
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------