MEDICARE: PED-E-CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency	60080992	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60080992	OTHER	FL	PPEC LICENSE NUMBER

General Provider Information

NPI Number	:	1003123696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PED-E-CARE

Provider Business Mailing Address
First Line	:	540 STATE ROAD 13
Second Line	:	SUITE 104
City	:	FRUIT COVE
State	:	FL
Zip	:	32259-3872
Country	:	US
Telephone Number	:	904-814-8209
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 STATE ROAD 13
Second Line	:	SUITE 104
City	:	FRUIT COVE
State	:	FL
Zip	:	32259-3872
Country	:	US
Telephone Number	:	904-814-8209
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF NURSING
Name	:	MRS. JANE T PARK
Credential	:	RN
Telephone Number	:	904-608-4688

Provider Enumeration Date	:	09/03/2010
Last Update Date	:	09/03/2010

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Directions to “PED-E-CARE ” Practice Location

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