Healthcare Provider Details

I. General information

NPI: 1740655158
Provider Name (Legal Business Name): WELL CHILD OF GEORGIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 NEW YORK ST
MEMPHIS TN
38104-5536
US

IV. Provider business mailing address

650 NEW YORK ST
MEMPHIS TN
38104-5536
US

V. Phone/Fax

Practice location:
  • Phone: 901-728-5858
  • Fax: 901-531-6312
Mailing address:
  • Phone: 901-728-5858
  • Fax: 901-531-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KAREN J PEASE
Title or Position: CEO
Credential:
Phone: 901-728-5858