Healthcare Provider Details

I. General information

NPI: 1003584327
Provider Name (Legal Business Name): LIFE CYCLE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MEDICAL WAY STE B
RIVERDALE GA
30274-2533
US

IV. Provider business mailing address

2739 FELTON DR
EAST POINT GA
30344-3603
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-2800
  • Fax: 770-692-2804
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 Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN WILLIAMS
Title or Position: OFFICE MANAGER
Credential:
Phone: 404-228-0601