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General NPI Number Information
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NPI Number | 1831732197
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Entity Type | Organization
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Legal Business Name | SPROUTS PEDIATRIC CLINIC, LLC
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Dates
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Enumeration Date | 10/18/2019
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Last Update Date | 10/18/2019
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Provider Practice Location Address
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Address Line | 200 VALENCIA DR STE 160
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City | JACKSONVILLE
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State | NC
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Zip | 28546-6315
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Country | US
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Telephone | 206-653-6090
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Fax |
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Provider Business Mailing Address
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Address Line | 301 LONDON BERRY LN
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City | JACKSONVILLE
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State | NC
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Zip | 28540-4243
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Country | US
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Telephone | 206-653-6090
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST / OWNER
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Name | KILEY THROOP
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Credential | MS, OTR/L
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Telephone | 206-653-6090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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