1487742532 NPI number — WESTCARE VILLA RICA PEDIATRICS

Table of content: (NPI 1487742532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487742532 NPI number — WESTCARE VILLA RICA PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTCARE VILLA RICA PEDIATRICS
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:
1487742532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
626 DALLAS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-459-9378
Provider Business Mailing Address Fax Number:
770-459-8613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
626 DALLAS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-459-9378
Provider Business Practice Location Address Fax Number:
770-459-8613
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAXWELL
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-832-2005

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: 203686572A . This is a "MEDICAID PAYEE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com