Provider Demographics
NPI:1619184132
Name:HEALTHY KIDS PEDIATRIC CENTER, P.C.
Entity Type:Organization
Organization Name:HEALTHY KIDS PEDIATRIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RESA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-858-0121
Mailing Address - Street 1:44075 PIPELINE PLZ
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5881
Mailing Address - Country:US
Mailing Address - Phone:703-858-0121
Mailing Address - Fax:703-858-0710
Practice Address - Street 1:44075 PIPELINE PLZ
Practice Address - Street 2:SUITE 210
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5881
Practice Address - Country:US
Practice Address - Phone:703-858-0121
Practice Address - Fax:703-858-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234951261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care