Healthcare Provider Details

I. General information

NPI: 1497277404
Provider Name (Legal Business Name): KIDS-DOC-ON-WHEELS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 E PONCE DE LEON AVE # 2
CLARKSTON GA
30021-8106
US

IV. Provider business mailing address

4112 E PONCE DE LEON AVE # 2
CLARKSTON GA
30021-8106
US

V. Phone/Fax

Practice location:
  • Phone: 404-574-2512
  • Fax: 404-296-7211
Mailing address:
  • Phone: 404-574-2512
  • Fax: 404-296-7211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier003193946A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: DR. LYNETTE R WILSON-PHILLIPS
Title or Position: BOARD OF DIRECTORS
Credential: MD
Phone: 404-574-2512