Healthcare Provider Details

I. General information

NPI: 1417044181
Provider Name (Legal Business Name): KIDCARE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 DANNON VW SW STE 2101
ATLANTA GA
30331-2156
US

IV. Provider business mailing address

910 DANNON VW SW STE 2101
ATLANTA GA
30331-2156
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-6100
  • Fax: 404-691-6959
Mailing address:
  • Phone: 404-691-6100
  • Fax: 404-691-6959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number057447
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAUNCEY DANIELS
Title or Position: CEO
Credential:
Phone: 404-765-9437