=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649880667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAYSON PEDIATRICS MOBILE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2020
-----------------------------------------------------
Last Update Date | 08/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 297 COOPER RD STE B
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-2518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-778-2429
-----------------------------------------------------
Fax | 470-410-8905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 297 COOPER RD STE B
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-2518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-778-2429
-----------------------------------------------------
Fax | 470-410-8905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER, CO-OWNER, CPNP
-----------------------------------------------------
Name | JULIE A OPEKA
-----------------------------------------------------
Credential | CPNP
-----------------------------------------------------
Telephone | 888-778-2429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------