1255688958 NPI number — KIDZCARE PEDIATRICS, PC

Table of content: (NPI 1255688958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255688958 NPI number — KIDZCARE PEDIATRICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDZCARE PEDIATRICS, PC
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:
6
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:
1255688958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9219
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28311-9082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-483-7337
Provider Business Mailing Address Fax Number:
910-483-0648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27332-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-775-7337
Provider Business Practice Location Address Fax Number:
919-775-1525
Provider Enumeration Date:
08/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKHART
Authorized Official First Name:
SHANTAE
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
CREDENTIALS MANAGER
Authorized Official Telephone Number:
910-483-7337

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016VR . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5921254 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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