Provider Demographics
NPI:1003584327
Name:LIFE CYCLE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:LIFE CYCLE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-228-0601
Mailing Address - Street 1:2739 FELTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3603
Mailing Address - Country:US
Mailing Address - Phone:404-766-8371
Mailing Address - Fax:404-767-3926
Practice Address - Street 1:150 MEDICAL WAY STE B
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2533
Practice Address - Country:US
Practice Address - Phone:770-692-2800
Practice Address - Fax:770-692-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1578526539Medicaid