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General NPI Number Information
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NPI Number | 1679766299
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Entity Type | Organization
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Legal Business Name | MOULTRIE PEDIATRICS, LLC
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Dates
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Enumeration Date | 08/27/2007
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Last Update Date | 10/27/2011
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Provider Practice Location Address
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Address Line | 1 SWEET BAY CT SUITE A
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City | MOULTRIE
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State | GA
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Zip | 31768-6756
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Country | US
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Telephone | 229-985-1293
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Fax | 229-891-2123
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Provider Business Mailing Address
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Address Line | PO BOX 129
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City | MOULTRIE
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State | GA
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Zip | 31776-0129
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Country | US
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Telephone | 229-985-1293
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Fax | 229-891-2123
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Authorized Official
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Title or Position | OWNER
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Name | MARION A WILLS
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Credential | M.D.
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Telephone | 229-985-1293
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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 |
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License Number State |
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