Healthcare Provider Details

I. General information

NPI: 1639472186
Provider Name (Legal Business Name): GROWING CHILD PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E HORTON ST
ZEBULON NC
27597-2820
US

IV. Provider business mailing address

11130 CAPITAL BLVD
WAKE FOREST NC
27587-4513
US

V. Phone/Fax

Practice location:
  • Phone: 919-269-2885
  • Fax: 919-488-1718
Mailing address:
  • Phone: 919-488-4094
  • Fax: 919-488-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DESI CUNA
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 919-488-0015