=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760602783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PEDIATRIC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-226-7544
-----------------------------------------------------
Fax | 229-226-0314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-226-7544
-----------------------------------------------------
Fax | 229-226-0314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RN,OFFICE MANAGER
-----------------------------------------------------
Name | TERESA CONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-226-7544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------