Provider Demographics
NPI:1295186468
Name:PEDSPLUS PEDIATRICS PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:PEDSPLUS PEDIATRICS PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-751-3641
Mailing Address - Street 1:1010 W KENSINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8003
Mailing Address - Country:US
Mailing Address - Phone:347-751-3641
Mailing Address - Fax:
Practice Address - Street 1:621 JEFFERSON DAVIS HWY UNIT 11B
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4567
Practice Address - Country:US
Practice Address - Phone:347-751-3641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243632208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty