1164432100 NPI number — KIDS & TEENS PRIMARY HEALTH CARE OF ATLANTA, P.C.

Table of content: (NPI 1164432100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164432100 NPI number — KIDS & TEENS PRIMARY HEALTH CARE OF ATLANTA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS & TEENS PRIMARY HEALTH CARE OF ATLANTA, P.C.
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:
1164432100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1462 MONTREAL RD
Provider Second Line Business Mailing Address:
STE 212
Provider Business Mailing Address City Name:
TUCKER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30084-6929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-875-4261
Provider Business Mailing Address Fax Number:
770-939-7750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1462 MONTREAL RD
Provider Second Line Business Practice Location Address:
STE 212
Provider Business Practice Location Address City Name:
TUCKER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30084-6929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-875-4261
Provider Business Practice Location Address Fax Number:
770-939-7750
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COTTON
Authorized Official First Name:
BYRON
Authorized Official Middle Name:
CEDRIC
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
404-875-4261

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  041098 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2080A0000X , with the licence number: 041098 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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