1710346267 NPI number — PEDIATRIC THERAPIES OF SE GA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710346267 NPI number — PEDIATRIC THERAPIES OF SE GA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC THERAPIES OF SE GA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710346267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
UNIT 7
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32207-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-996-2069
Provider Business Mailing Address Fax Number:
912-265-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 HOSPITALITY AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
KINGSLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31548-6810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-996-2069
Provider Business Practice Location Address Fax Number:
912-265-0041
Provider Enumeration Date:
02/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
OWNER/OPERATOR/PROVIDER
Authorized Official Telephone Number:
912-996-2069

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OT001375 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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