Provider Demographics
NPI:1073063459
Name:247 KID DOC
Entity Type:Organization
Organization Name:247 KID DOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:BAIN
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-303-8006
Mailing Address - Street 1:3304 STONESTHROW DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-8883
Mailing Address - Country:US
Mailing Address - Phone:844-303-8006
Mailing Address - Fax:
Practice Address - Street 1:3304 STONESTHROW DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-8883
Practice Address - Country:US
Practice Address - Phone:844-303-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-02169261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care