Healthcare Provider Details

I. General information

NPI: 1760431605
Provider Name (Legal Business Name): SANTO NINO PEDIATRIC CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 CENTRAL AVE
AUGUSTA GA
30904-5737
US

IV. Provider business mailing address

1722 CENTRAL AVE
AUGUSTA GA
30904-5737
US

V. Phone/Fax

Practice location:
  • Phone: 706-855-7414
  • Fax: 706-364-0554
Mailing address:
  • Phone: 706-855-7414
  • Fax: 706-364-0554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. ALBERTO RICO NAFARRETE
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-855-7414