=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811361207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY KIDS PEDIATRICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2015
-----------------------------------------------------
Last Update Date | 07/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 FRANKLIN AVE
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-437-5455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 675 FRANKLIN AVE
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-437-5455
-----------------------------------------------------
Fax | 862-238-7454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGING MEMBER
-----------------------------------------------------
Name | DR. JILL GARRIPOLI PEDALINO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 844-437-5455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 25MB07995400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------