Healthcare Provider Details

I. General information

NPI: 1134286248
Provider Name (Legal Business Name): PEDIATRIC CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 VILLAGE PROFESSIONAL DRIVE
OPELIKA AL
36801-4702
US

IV. Provider business mailing address

2401 VILLAGE PROFESSIONAL DRIVE
OPELIKA AL
36801-4702
US

V. Phone/Fax

Practice location:
  • Phone: 334-749-8121
  • Fax: 334-749-6166
Mailing address:
  • Phone: 334-749-8121
  • Fax: 334-749-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID BRYANT SMALLEY
Title or Position: PARTNER
Credential: M.D.
Phone: 334-749-8121