Provider Demographics
NPI:1497277404
Name:KIDS-DOC-ON-WHEELS
Entity Type:Organization
Organization Name:KIDS-DOC-ON-WHEELS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILSON-PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-574-2512
Mailing Address - Street 1:4112 E PONCE DE LEON AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-8106
Mailing Address - Country:US
Mailing Address - Phone:404-574-2512
Mailing Address - Fax:404-296-7211
Practice Address - Street 1:4112 E PONCE DE LEON AVE # 2
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-8106
Practice Address - Country:US
Practice Address - Phone:404-574-2512
Practice Address - Fax:404-296-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003193946AMedicaid