=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295186468
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDSPLUS PEDIATRICS PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2016
-----------------------------------------------------
Last Update Date | 06/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 JEFFERSON DAVIS HWY UNIT 11B
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-751-3641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 W KENSINGTON CIR
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22401-8003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-751-3641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JEAN LAURORE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 347-751-3641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0101243632
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------