Healthcare Provider Details

I. General information

NPI: 1467623124
Provider Name (Legal Business Name): PEDIATRIC MOBILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 COLLEGE ST
MACON GA
31201-1607
US

IV. Provider business mailing address

1058 WARWICK DR
MACON GA
31210-1540
US

V. Phone/Fax

Practice location:
  • Phone: 478-951-7576
  • Fax:
Mailing address:
  • Phone: 478-474-5641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: TED L HYDE
Title or Position: OWNER/MANAGER
Credential:
Phone: 478-474-5641