MEDICARE: NIGHT LITE PEDIATRIC CENTER, LLC

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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093474025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIGHT LITE PEDIATRIC CENTER, LLC

Provider Business Mailing Address
First Line	:	1 HOLLOW LANE
Second Line	:	SUITE 301
City	:	LAKE SUCCESS
State	:	NY
Zip	:	11042
Country	:	US
Telephone Number	:	516-207-7936
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 W LAKE MARY BLVD
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-6159
Country	:	US
Telephone Number	:	407-585-0568
Fax Number	:

Authorized Official
Title or Position	:	MANAGER OF CREDENTIALING AND ENROL
Name	:	DANIELLE MARIE LOPEZ
Credential	:
Telephone Number	:	516-207-7936

Provider Enumeration Date	:	12/17/2021
Last Update Date	:	01/21/2025

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