NPIMap

Organization Active NPI

Acute Care Pediatrics of Palm Coast, PA

  • Rural Health Clinic/Center
  • Palm Coast, FL
National Provider Identifier
1225065717
Registry record updated Jul 31, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ACUTE CARE PEDIATRICS OF PALM COAST, PA
Practice address
397 Palm Coast Parkway SW
Unit 303
Palm Coast, FL 32137
Phone
(386) 447-7337
Fax
(386) 447-7348
NPI assigned
Jun 28, 2006
Last updated
Jul 31, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 31, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Christine Tiu, LPN
Title
Office Manager
Phone
(386) 447-7337

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X ME 0075674 FL
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

397 Palm Coast Parkway SW
Unit 303
Palm Coast, FL 32137

Mailing address

397 Palm Coast Parkway SW
Unit 303
Palm Coast, FL 32137
Phone (386) 447-7337

Other identifiers 2

IdentifierTypeStateIssuer
009USOtherFLBLUE CROSS BLUE SHIELD OF FLORIDA
000387200MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071016000038 FL Part A Provider - Rural Health Clinic 5496841942 Practice locations: Palm Coast, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1225065717. Details of each certification follow.

Rural health clinic certification: CCN 108997

Legal name
ACUTE CARE PEDIATRICS OF PALM COAST PA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 13, 2008
Last certification
Jun 25, 2020
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Jan 1, 2006 in FL
Enrollment address
397 Palm Coast Pkwy SW
Suite 303
Palm Coast, FL 32137-4776

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D1049486Acute Care Pediatrics of Palm Coast PA397 Palm Coast Pkwy #303, Palm Coast, FL 32137Certificate of waiverJan 8, 2028

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

397 Palm Coast Pkwy SW
Ste 303
Palm Coast, FL 32137
Phone (386) 447-7337

397 Palm Coast Pkwy SW
Unit 303
Palm Coast, FL 32137
Phone (386) 447-7337

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Pamela G Santelices Individual Operational/Managerial ControlOperational Director May 1, 2024
Samuel Santelices Individual 5% Or Greater Indirect Ownership Interest May 1, 2024 100%
Operational/Managerial ControlCeo May 1, 2024
North Florida Pediatrics, PA Organization, Lake City, FL Corporation, For-profit, Owned by another organization or individual 5% Or Greater Direct Ownership Interest May 1, 2024 100%

Owners & managing parties with NPI records 8

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151452800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690761600000",
    "number": "1225065717",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "397 PALM COAST PARKWAY SW",
            "address_2": "UNIT 303",
            "city": "PALM COAST",
            "state": "FL",
            "postal_code": "32137",
            "telephone_number": "386-447-7337",
            "fax_number": "386-447-7348"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "397 PALM COAST PARKWAY SW",
            "address_2": "UNIT 303",
            "city": "PALM COAST",
            "state": "FL",
            "postal_code": "32137",
            "telephone_number": "386-447-7337",
            "fax_number": "386-447-7348"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ACUTE CARE PEDIATRICS OF PALM COAST, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-28",
        "last_updated": "2023-07-31",
        "certification_date": "2023-07-31",
        "status": "A",
        "authorized_official_last_name": "TIU",
        "authorized_official_first_name": "CHRISTINE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "386-447-7337",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LPN"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "FL",
            "license": "ME 0075674",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD OF FLORIDA",
            "identifier": "009US",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000387200",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Palm Coast, FL

Sources for this page

Verify at the official NPI Registry.