Provider Demographics
NPI:1760431605
Name:SANTO NINO PEDIATRIC CLINIC, PC
Entity Type:Organization
Organization Name:SANTO NINO PEDIATRIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:RICO
Authorized Official - Last Name:NAFARRETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-855-7414
Mailing Address - Street 1:1722 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5737
Mailing Address - Country:US
Mailing Address - Phone:706-855-7414
Mailing Address - Fax:706-364-0554
Practice Address - Street 1:1722 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5737
Practice Address - Country:US
Practice Address - Phone:706-855-7414
Practice Address - Fax:706-364-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5444457OtherCCN(NETWORK)
SCGPA837Medicaid
GA10942549OtherCAROLINA CARE PLAN
GA003683189AMedicaid
GA003683189AMedicaid
GA5444457OtherCCN(NETWORK)
GA=========OtherBLUE CROSS BLUE SHIELDS
GA=========OtherFIRST HEALTH (NETWORK)
GA=========OtherBEECH STREET CORP.
GA=========OtherPHCS(PRIVATE HEALTH SYS.)