Provider Demographics
NPI:1407974579
Name:NIGHT LITE PEDIATRIC CENTER, LLC
Entity type:Organization
Organization Name:NIGHT LITE PEDIATRIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-207-7936
Mailing Address - Street 1:1 HOLLOW LN STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1215
Mailing Address - Country:US
Mailing Address - Phone:516-207-7936
Mailing Address - Fax:516-207-7936
Practice Address - Street 1:5900 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-3716
Practice Address - Country:US
Practice Address - Phone:407-398-6470
Practice Address - Fax:407-894-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061521208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279344000Medicaid