Provider Demographics
NPI:1477815306
Name:ZOE CENTER FOR PEDIATRIC & ADOLESCENT HEALTH, LLC
Entity Type:Organization
Organization Name:ZOE CENTER FOR PEDIATRIC & ADOLESCENT HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-938-0990
Mailing Address - Street 1:210 HANNAHS MILL RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-2801
Mailing Address - Country:US
Mailing Address - Phone:706-938-0990
Mailing Address - Fax:706-647-3861
Practice Address - Street 1:100 HIGHWAY 18 W
Practice Address - Street 2:STE 201
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1171
Practice Address - Country:US
Practice Address - Phone:706-938-0990
Practice Address - Fax:706-647-3861
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZOE CENTER FOR PEDIATRIC & ADOLESCENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty