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General NPI Number Information
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NPI Number | 1982858767
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Entity Type | Organization
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Legal Business Name | SOUTHERN PEDIATRIC CLINIC, LLC
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Dates
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Enumeration Date | 11/06/2008
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Last Update Date | 02/03/2017
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Provider Practice Location Address
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Address Line | 406 M NORTHSIDE DRIVE
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City | VALDOSTA
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State | GA
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Zip | 31602
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Country | US
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Telephone | 229-241-0059
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Fax | 229-241-0059
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Provider Business Mailing Address
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Address Line | 406 M NORTHSIDE DRIVE
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City | VALDOSTA
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State | GA
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Zip | 31602
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Country | US
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Telephone | 229-241-0059
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Fax | 229-241-2088
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. CHARLENE C BLACHE
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Credential | M.D.
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Telephone | 229-241-0059
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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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