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General NPI Number Information
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NPI Number | 1861136483
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE PEDIATRICS LLC
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Dates
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Enumeration Date | 04/21/2022
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Last Update Date | 09/09/2022
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Provider Practice Location Address
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Address Line | 3610 PIEDMONT RD NE STE 100
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City | ATLANTA
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State | GA
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Zip | 30305-1406
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Country | US
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Telephone | 470-697-1396
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Fax |
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Provider Business Mailing Address
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Address Line | 3610 PIEDMONT RD NE STE 100
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City | ATLANTA
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State | GA
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Zip | 30305-1406
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Country | US
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Telephone | 470-697-1396
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRITTANY WILSON
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Credential | MD
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Telephone | 470-697-1396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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