Healthcare Provider Details

I. General information

NPI: 1558096479
Provider Name (Legal Business Name): ATLANTA PEDIATRIC NUTRITION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 07/24/2022
Certification Date: 07/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 ROCKY CREEK TRL
WOODSTOCK GA
30188-6246
US

IV. Provider business mailing address

140 ROCKY CREEK TRL
WOODSTOCK GA
30188-6246
US

V. Phone/Fax

Practice location:
  • Phone: 404-543-3897
  • Fax: 404-745-0808
Mailing address:
  • Phone: 404-543-3897
  • Fax: 404-745-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. HELEN BAILEY KOCH
Title or Position: PRESIDENT
Credential: RD, CSP, LD
Phone: 404-543-3897