Provider Demographics
NPI:1396095998
Name:PEDIATRIC CARE CENTER INC
Entity type:Organization
Organization Name:PEDIATRIC CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:ARMANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-432-1822
Mailing Address - Street 1:2135 S CONGRESS AVE STE 2C
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7611
Mailing Address - Country:US
Mailing Address - Phone:561-432-1822
Mailing Address - Fax:561-432-0108
Practice Address - Street 1:2135 S CONGRESS AVE STE 2C
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-7611
Practice Address - Country:US
Practice Address - Phone:561-432-1822
Practice Address - Fax:561-432-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063404261QP2300X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003999000Medicaid
FL114618000Medicaid
FL379462800Medicaid