Healthcare Provider Details

I. General information

NPI: 1578649869
Provider Name (Legal Business Name): CHILDRENS MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 LANEY WALKER BLVD
AUGUSTA GA
30901-2960
US

IV. Provider business mailing address

161 STONE MILL DR
MARTINEZ GA
30907-1659
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-5810
  • Fax:
Mailing address:
  • Phone: 706-863-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0367436743
License Number StateGA

VIII. Authorized Official

Name: MRS. CAROL A HENDRICKSON
Title or Position: PUBLIC HEATH NURSE SPECIALIST
Credential: R.N., BSN
Phone: 706-721-5810