Basic Information
| Provider Information | |||||||||
| NPI: | 1487927810 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NICKLAUS CHILDREN'S HOSPITAL PALM BEACH GARDENS OUTPATIENT CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NICKLAUS CHILDREN'S PALM BEACH GARDENS OUTPATIENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 557367 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332557367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866245876 | ||||||||
| FaxNumber: | 7866242688 | ||||||||
| Practice Location | |||||||||
| Address1: | 11310 LEGACY AVE | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334103658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056666511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VIDAURRAZAGA | ||||||||
| AuthorizedOfficialFirstName: | RAIZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7865255405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VARIETY CHILDREN'S HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282NC2000X | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 010060930 | 05 | FL | MEDICAID |