Healthcare Provider Details

I. General information

NPI: 1629302260
Provider Name (Legal Business Name): KIDS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 NORMAN DORMINY DR STE A
FITZGERALD GA
31750-8855
US

IV. Provider business mailing address

PO BOX 1027
FITZGERALD GA
31750-1027
US

V. Phone/Fax

Practice location:
  • Phone: 229-423-5437
  • Fax: 229-424-0868
Mailing address:
  • Phone: 229-423-5437
  • Fax: 229-424-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number026873
License Number StateGA

VIII. Authorized Official

Name: MRS. LARA MILLS
Title or Position: OFFICE MANAGER
Credential:
Phone: 229-424-7341