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General NPI Number Information
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NPI Number | 1811241417
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Entity Type | Organization
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Legal Business Name | VIBRANT KIDS PEDIATRICS, LLC
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Dates
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Enumeration Date | 11/04/2012
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Last Update Date | 11/04/2012
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Provider Practice Location Address
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Address Line | 10 MARKET SQUARE WAY STE 100
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City | NEWNAN
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State | GA
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Zip | 30265-6078
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Country | US
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Telephone | 678-423-5560
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Fax | 678-423-5563
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Provider Business Mailing Address
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Address Line | 87 TAPESTRY LN
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City | NEWNAN
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State | GA
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Zip | 30265-5649
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Country | US
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Telephone | 678-423-5560
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Fax | 678-423-5563
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Authorized Official
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Title or Position | MANAGER
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Name | JILL BURNETT DICKERSON
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Credential | MD
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Telephone | 678-423-5560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 061061
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License Number State | GA
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