Healthcare Provider Details

I. General information

NPI: 1841732138
Provider Name (Legal Business Name): SUNRISE PEDIATRIC NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 CANTON RD BUILDING1
MARIETTA GA
30066-2896
US

IV. Provider business mailing address

3417 CANTON RD BUILDING 1
MARIETTA GA
30066-2896
US

V. Phone/Fax

Practice location:
  • Phone: 678-606-5700
  • Fax:
Mailing address:
  • Phone: 678-606-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERISE FRAZIER
Title or Position: OWNER
Credential:
Phone: 678-606-5700