MEDICARE: KIDZCARE PEDIATRICS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1972015097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDZCARE PEDIATRICS, PC

Provider Business Mailing Address
First Line	:	5617 RAMSEY ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-1423
Country	:	US
Telephone Number	:	910-483-7337
Fax Number	:	910-483-0648

Provider Business Practice Location Address
First Line	:	112 MEDICAL VILLAGE DR STE D
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1665
Country	:	US
Telephone Number	:	910-665-1437
Fax Number	:	910-665-1315

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	SHANTAE RENEE LOCKHART
Credential	:
Telephone Number	:	910-483-7337

Provider Enumeration Date	:	10/30/2017
Last Update Date	:	10/30/2017

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