Provider Demographics
NPI:1699224527
Name:ROBERTS, CEDRIC
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOS 237
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:GA
Mailing Address - Zip Code:31647
Mailing Address - Country:US
Mailing Address - Phone:229-251-5041
Mailing Address - Fax:
Practice Address - Street 1:3037 JODECO RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-4709
Practice Address - Country:US
Practice Address - Phone:229-251-5041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA621410171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor