Healthcare Provider Details

I. General information

NPI: 1356226203
Provider Name (Legal Business Name): RAVEN CHILDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PEACHTREE ST NW STE 2200
ATLANTA GA
30303-1292
US

IV. Provider business mailing address

1122 OAK KNOLL TER SE
ATLANTA GA
30315-5214
US

V. Phone/Fax

Practice location:
  • Phone: 404-429-8377
  • Fax:
Mailing address:
  • Phone: 404-429-8377
  • Fax: 404-429-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number11D2327258
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: