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General NPI Number Information
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NPI Number | 1396145058
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Entity Type | Organization
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Legal Business Name | WALTON CHILDREN'S CLINIC
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Dates
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Enumeration Date | 09/01/2014
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Last Update Date | 09/23/2015
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Provider Practice Location Address
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Address Line | 98 TARA COMMONS DR SUITE 400
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City | LOGANVILLE
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State | GA
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Zip | 30052-8031
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Country | US
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Telephone | 770-207-5437
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Fax | 770-207-7263
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Provider Business Mailing Address
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Address Line | 98 TARA COMMONS DR SUITE 400
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City | LOGANVILLE
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State | GA
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Zip | 30052-8031
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Country | US
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Telephone | 770-207-5437
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Fax | 770-207-7263
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Authorized Official
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Title or Position | PRESIDENT
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Name | EBBA K EBBA
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Credential | MD
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Telephone | 770-207-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036724
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License Number State | GA
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