Healthcare Provider Details

I. General information

NPI: 1134331952
Provider Name (Legal Business Name): LIFE CYCLE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2739 FELTON DR
EAST POINT GA
30344-3603
US

IV. Provider business mailing address

2739 FELTON DR
EAST POINT GA
30344-3603
US

V. Phone/Fax

Practice location:
  • Phone: 404-766-8371
  • Fax: 404-767-3926
Mailing address:
  • Phone: 404-766-8371
  • Fax: 404-767-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number046192
License Number StateGA

VIII. Authorized Official

Name: ANNE SIGOUIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 404-766-8371