Provider Demographics
NPI:1568766293
Name:PEBE MED, INC
Entity Type:Organization
Organization Name:PEBE MED, INC
Other - Org Name:CHILDREN FIRST PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSALITO
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-231-5977
Mailing Address - Street 1:786 LOCKS WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4976
Mailing Address - Country:US
Mailing Address - Phone:706-231-5977
Mailing Address - Fax:706-868-0929
Practice Address - Street 1:1267 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6481
Practice Address - Country:US
Practice Address - Phone:706-868-0919
Practice Address - Fax:706-868-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051131261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000940354EMedicaid