Healthcare Provider Details

I. General information

NPI: 1699129080
Provider Name (Legal Business Name): HEALTHY KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 N THOMPSON LN SUITE E
MURFREESBORO TN
37129-4310
US

IV. Provider business mailing address

452 N THOMPSON LN SUITE E
MURFREESBORO TN
37129-4310
US

V. Phone/Fax

Practice location:
  • Phone: 615-900-3301
  • Fax: 615-962-9328
Mailing address:
  • Phone: 615-900-3301
  • Fax: 615-962-9328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37838
License Number StateTN

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. SAMER LOLEH
Title or Position: PRINCIPAL OFFICER
Credential: M.D.
Phone: 615-900-3301