Healthcare Provider Details

I. General information

NPI: 1144674177
Provider Name (Legal Business Name): KIDZ KONNECTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 AVALON WAY APT 313
BRANDON MS
39047-7533
US

IV. Provider business mailing address

2460 TERRY RD SUITE 700
JACKSON MS
39204-5767
US

V. Phone/Fax

Practice location:
  • Phone: 404-279-0598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ASYA JOY LOPEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-279-0598