Healthcare Provider Details

I. General information

NPI: 1811945835
Provider Name (Legal Business Name): KYENDRIA KELLOGG GARTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ZEBULON ROAD
GRIFFIN GA
30224
US

IV. Provider business mailing address

1900 ZEBULON ROAD
GRIFFIN GA
30224
US

V. Phone/Fax

Practice location:
  • Phone: 770-227-5510
  • Fax: 770-228-8180
Mailing address:
  • Phone: 770-227-5510
  • Fax: 770-228-8180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number051293
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: