Provider Demographics
NPI:1467623124
Name:PEDIATRIC MOBILITY
Entity Type:Organization
Organization Name:PEDIATRIC MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:L
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-474-5641
Mailing Address - Street 1:1058 WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1540
Mailing Address - Country:US
Mailing Address - Phone:478-474-5641
Mailing Address - Fax:
Practice Address - Street 1:130 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1607
Practice Address - Country:US
Practice Address - Phone:478-951-7576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier