Healthcare Provider Details

I. General information

NPI: 1750420428
Provider Name (Legal Business Name): SHORE FUN PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOCTORS CIR SUITE 3
SUPPLY NC
28462-4097
US

IV. Provider business mailing address

14 DOCTORS CIR SUITE 3
SUPPLY NC
28462-4097
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-7075
  • Fax: 910-754-2158
Mailing address:
  • Phone: 910-754-7075
  • Fax: 910-754-2158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. BRUCIE JANELLE SPIVEY-COCHRAN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 910-754-7075