Healthcare Provider Details

I. General information

NPI: 1063688224
Provider Name (Legal Business Name): LIFE CYCLE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107B UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2540
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 Number046192
License Number StateGA

VIII. Authorized Official

Name: DR. DORSEY NORWOOD
Title or Position: PHYSICIAN
Credential: MD
Phone: 770-692-2800