Provider Demographics
NPI:1356988661
Name:PEDS PURPOSE LLC
Entity type:Organization
Organization Name:PEDS PURPOSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-602-6023
Mailing Address - Street 1:140 GREAT RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-3048
Mailing Address - Country:US
Mailing Address - Phone:240-602-6023
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 N STE 104
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:856-230-7208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty