Healthcare Provider Details

I. General information

NPI: 1487577961
Provider Name (Legal Business Name): BLUESPRIG PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 MERCHANTS SQ
DALLAS GA
30132-5029
US

IV. Provider business mailing address

296 MERCHANTS SQ
DALLAS GA
30132-5029
US

V. Phone/Fax

Practice location:
  • Phone: 407-915-7720
  • Fax:
Mailing address:
  • Phone: 407-915-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: EZECHIMERE ISRAEL CHIKEZIE
Title or Position: RBT
Credential:
Phone: 404-553-3031