Healthcare Provider Details

I. General information

NPI: 1871689265
Provider Name (Legal Business Name): KIDCARE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 JOLLY RD STE A
COLLEGE PARK GA
30349-3103
US

IV. Provider business mailing address

2565 JOLLY RD STE A
COLLEGE PARK GA
30349-3103
US

V. Phone/Fax

Practice location:
  • Phone: 404-765-9437
  • Fax: 404-669-9347
Mailing address:
  • Phone: 404-765-9437
  • Fax: 404-669-9347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number027494
License Number StateGA

VIII. Authorized Official

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