MEDICARE: BRIGHT STAR PEDIATRIC AND ADOLECENT CENTER

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	363LP0200X	Pediatric Nurse Practitioner	2080412	FL

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	:	1629445846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHT STAR PEDIATRIC AND ADOLECENT CENTER

Provider Business Mailing Address
First Line	:	PO BOX 1132
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-1132
Country	:	US
Telephone Number	:	850-374-2311
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 BAY GROVE BLVD
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-1725
Country	:	US
Telephone Number	:	850-374-2311
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MS. LINDA IDEAN RICH
Credential	:	ARNP
Telephone Number	:	850-374-2311

Provider Enumeration Date	:	08/24/2015
Last Update Date	:	08/24/2015

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