Healthcare Provider Details

I. General information

NPI: 1255952347
Provider Name (Legal Business Name): OUR VILLAGE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ACADEMY ST
CANTON GA
30114-2860
US

IV. Provider business mailing address

115 ACADEMY ST
CANTON GA
30114-2860
US

V. Phone/Fax

Practice location:
  • Phone: 470-389-4970
  • Fax:
Mailing address:
  • Phone: 470-389-4970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JUSTIN GLAESER
Title or Position: OFFICE MANAGER
Credential:
Phone: 470-389-4970