Healthcare Provider Details

I. General information

NPI: 1629394614
Provider Name (Legal Business Name): KIDZCARE PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 N BRAGG BOULEVARD
SPRING LAKE NC
28390-2709
US

IV. Provider business mailing address

PO BOX 647
HOPE MILLS NC
28348-0647
US

V. Phone/Fax

Practice location:
  • Phone: 910-495-7337
  • Fax: 910-495-0747
Mailing address:
  • Phone: 910-483-7337
  • Fax: 910-483-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5914484
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier016VR
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS NC
# 3
Identifier016VP
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS NC
# 4
Identifier1342H
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name: MS. REBECCA E WRIGHT
Title or Position: CREDENTIALS MANAGER
Credential:
Phone: 910-483-7337