Provider Demographics
NPI:1902554041
Name:THE PEACH PIT LLC
Entity Type:Organization
Organization Name:THE PEACH PIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRADILLADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-809-5461
Mailing Address - Street 1:9861 ROBINS NEST RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2144
Mailing Address - Country:US
Mailing Address - Phone:561-809-5461
Mailing Address - Fax:
Practice Address - Street 1:2216 S JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33415-6101
Practice Address - Country:US
Practice Address - Phone:561-412-5577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020460500Medicaid